L
N
o
Ag
Ad
1.
2.
n
o
3.
Y
o
Y
o
L
eslie C. G
r
Town Cle
r
o
minee
N
g
ency/Or
g
d
dress:
How has
Has you
r
o
table?
In your o
w
o
ur Name:
o
ur Addres
s
This for
m
oss
r
k
N
ame:
g
anizatio
n
If
your nomi
n
r
nominee
o
w
n words,
s
:
m
may be c
o
TO
W
HO
M
N
n
(if appli
c
NO
M
P
If
necessary,
y
n
ee impact
o
vercome a
w
hy shoul
d
T
2
M
o
pied and
g
W
N OF N
O
M
ETO
W
N
OMIN
A
c
able):
M
INEE
C
P
rint or typ
e
y
ou may ad
d
ed the well
n
y special
c
d
your nom
i
T
own Cler
k
2
00 Pland
o
M
anhasse
t
g
iven to a f
r
O
RTH HE
W
N
H
A
TION
F
Te
l
C
ONTRI
B
e
entire for
m
d
one add
i
tio
n
-being of t
h
c
hallenges
i
nee be ch
o
Yo
u
k
Leslie G
r
o
me Road
t
, NY 1103
0
r
iend for ot
h
MPSTE
A
H
ERO
F
ORM
l
ephone:
B
UTION
S
m
clearly
n
al page per
n
h
e commu
n
making his
/
o
sen as a
H
u
r Telepho
n
r
oss
0
h
er nomina
t
A
D
ES
S
n
ominee
n
ity? (state
/
her achie
v
H
ometown
n
e:
t
ion
s
specific ac
t
v
ements ev
e
Hero?
t
ivities)
e
n more
Additional Comments: