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Animal
Community Impact
Educator
Firefighter
Good Neighbor
Law Enforcement
Medical
Workplace Safety
Youth Samaritan
*Name of Nominee
*Address of Nominee
*City
*State
*Phone
*E-mail
*Location of Heroic Event
*Date of Heroic Event
*Name of Nominator
*Address of Nominator
*City
*State
*Phone
*E-mail
*Name of Witness
*Witness Phone
*Name of Witness
*Witness Phone
Description of Heroic Act: