UNITED STATES QUAD RUGBY ASSOCIATION
HALL OF FAME NOMINATION FORM

Nominee's Name: _________________________________________Date:__________

Address:_________________________________________________________________

City: ____________________________ State __________ Zip_____________________

Age:____________________Phone:___________________________________________

Disability:______________________________Occupation:____________________

PERSONAL INFORMATION OF NOMINEE; (Education, Service Record, Marital Status, Etc.)

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

SPORTS PARTICIPATION AWARDS;

Regional:__________________________________________________________________

National:__________________________________________________________________

International:________________________________________________________________
(Where additional sheets required please state "see attached")

Name of person submitting nomination: _______________________________________

Address:___________________________________________________________________

City: _______________________________ State __________ Zip_____________________

Team Affiliation:_________________________________________________________

Your Signature: ____________________________________Date__________________

Related Pages: Letter of Introduction - Hall of Fame Criteria for Selection

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