MOTHERS AGAINST DRUNK DRIVING ‘ TAKE THE WHEEL ’ 2023 RECOGNITION AWARDS
COMMUNITY PARTNER NOMINATION FORM
Community Partner - Given to a community partner who shows an outstanding dedication in areas of DWI/DUI education, prevention, or innovation to reduce underage driving and or impaired driving.
(PLEASE TYPE) Your Name (including rank): Your Organization: Your Street Address: Your City/State/Zip Code:
Your Daytime Phone: Your Email Address:
Nominee Name (including rank): Nominee Organization: Nominee Address: Nominee City/State/Zip Code:
Nominee Daytime Phone: Nominee Email Address:
REASON FOR NOMINATION:
Completed nomination forms must be emailed NO LATER THAN – April 3, 2023, to: Emma Dugas – State Program Manager, MADD North Texas emma.dugas@madd.org
Please call 214.637.0372 x 4828 if you have questions.
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