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Your  Name: _____________________________________________________________________ 

Phone Number: (         )______-______________ 

Address: _______________________________________________________________________ 

City ________________________________________State ________________Zip _____________

 Information about the Nominee:

Person you are nominating to win a customized Rodolfo Valentin wig or hairpiece.
 

Name: _______________________________________________________________________
 

Age: ______________
 

Phone: (      ) ______-______________
 

Address:_______________________________________________________________________
 

City _________________________________________State _______________Zip ____________
 

Email:_________________________________________________________________________
 

Illness or reason for hair loss:_____________________________________________________
 

Does this person know you are nominating him/her?__________________________________
 

Is this candidate also facing financial challenges? (Proof of Income will be required).

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Please give a brief statement on why you think this person would benefit from receiving a customized hairpiece or wig:

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     Thank you for your nomination. Winners will be notified directly by phone or mail.