Do you know someone who deserves to be considered for the Iowa Smiles Award? Fill out this form to nominate them. If you'd prefer to submit your nomination via mail or fax, click here for a downloadable PDF form.

Your Information:

YOUR NAME:


YOUR E-MAIL ADDRESS:


YOUR DAYTIME PHONE NUMBER:


Nominee Information:

NAME OF PERSON NOMINATED FOR THE AWARD:


STREET ADDRESS:


CITY:


STATE:


ZIP CODE:


DAYTIME PHONE NUMBER:


E-MAIL ADDRESS:


HOW DO YOU KNOW THIS PERSON?


WHAT DOES THIS PERSON DO TO PUT SMILES ON THE FACES OF OTHERS?
(Please provide specific examples.)


WHY DOES THIS PERSON DESERVE TO WIN THE IOWA SMILES AWARD?
(Please provide specific examples.)


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