If you are interested in being the next Man or Woman of the Year or would like to nominate someone you know, please fill out our official nomination form.

*required fields

Man & Woman of the Year Registration Form

YES! I will participate in the Man & Woman of the Year competition to benefit The Leukemia & Lymphoma Society. By sending in this form, I am pledging to raise a minimum of $1,500 for the fight against leukemia, lymphoma and blood cancers.

I would like to nominate a candidate for the Man & Woman of the Year.

Candidate/Nominator Contact Information*
Home Address*
City*
State*	Choose a State/Province Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland And Labrador North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon
Zip/Postal Code*
Phone*
Email*
Fax
Company
Title
Address
Work Phone
Work Fax
Email*
Local Newspaper

Nominee Information

Name of Candidate Nominee
Address
City
State	Choose a State/Province Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland And Labrador North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon
Zip/Postal Code
Day Phone
Email