Submitter
Your Name:
*
Address 1:
Address 2:
City:
State:
Zip:
*
Phone:
*
E-mail:
*
Do you agree to be filmed and broadcast on KTVI FOX 2
*
Yes
No
Are you available to shoot a segment between 10am and 5pm weekdays?
*
Yes
No
Nominee
Name Of Nominee
*
Address 1:
Address 2:
City:
State:
Zip:
Are you related to the person you want to help?
*
Yes
No
Is Your Nominee Employed?
*
Yes
No
If Yes. Where do they work at and what hours do they work?
Write us a brief paragraph of why you want to help this person
*
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