Survey - Leaders Circle Nomination Form

Leaders Circle Nomination Form

Please use this form to nominate individuals who you feel are appropriate honorees for the MS Leaders Circle. We would also like you to take a personal role in recruiting these individuals as honorees and work with them to fulfill their fundraising commitment.

Prospective Honoree Criteria:

Business professionals with five or more years on a career path
Director level and above
Demonstrated community service
Willingness to make a difference in the MS community

1.

Please enter YOUR contact information:

*

Title:

*

First Name: Required

Middle Name:

*

Last Name: Required

Suffix:

Professional Suffix:

*

Email: Required

*

Street 1: Required

Street 2:

*

City: Required

*

State/Province Required

*

ZIP / Postal Code: Required

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Phone Number: Required

*

Employer: Required

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Occupation: Required

Gender:

Date of Birth:

Month

Day

Year

Yes, I would like to receive important e-mail updates from the National MS Society.

Yes, I would like to receive important postal mail updates - including event announcements - from the National MS Society.

Remember me. What's this?

*2.

Question - Required - What is your title?

Information about the Nominee:

*3.

Question - Required - Nominee's Full Name:

*4.

Question - Required - Nominee's Title:

*5.

Question - Required - Nominee's Company Name:

*6.

Question - Required - Company's Address: (Include Street, City, State & Zip):

*7.

Question - Required - Nominee's Address: (Include Street, City, State & Zip):

*8.

Question - Required - Nominee's Daytime Phone:

*9.

Question - Required - Nominee's Email Address:

*10.

Question - Required - Nominee's relationship, if any, to MS?

As part of the MS Leaders Circle campaign, honorees are asked to
raise $1,500. Our staff serves as support along the way.

*11.

Question - Required - Please indicate how your nominee can serve as a fundraising ambassador:

*12.

Question - Required - Please explain briefly why this person is a good candidate for the MS Leaders Circle:

National Multiple Sclerosis Society

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