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To nominate a practice, procedure, facility, organization, publication, or other program as a Best Practice, complete the information on this form and fax the completed form to Dr. Walter G. Green III, (804) 289-8138 or mail it to P. O. Box 799, Glen Allen, Virginia 23060-0799.
Program or activity name:____________________________________________________
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Type of activity:________________________________________________________
Date covered by nomination:______________________________________________
Organization conducting program:__________________________________________
Description of program or activity:_____________________________________________
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Why is this a Best Practice:___________________________________________________
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Name:________________________________________________________________
Title:_________________________________________________________________
Telephone:__________________________________
E-Mail:_____________________________________
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