End Abuse Long Beach
CHILD ABUSE & DOMESTIC VIOLENCE PREVENTION COUNCIL
P.O. BOX 1548, LONG BEACH, CA 90801-1548
Since 1975
www.EndAbuseLB.org

ANNUAL AWARD NOMINATION FORM 2012

Child Protection & Domestic Violence Prevention

Each December, End Abuse Long Beach honors community members for their outstanding contributions in the prevention of domestic violence, child abuse, sexual assault, elder abuse, substance abuse or other related issues.
To make a nomination, please complete as follows:

Your Nominee:

First Name:    Last:
Street:
City:    State     Zip:
Specify reason for nomination:

Your Information:

First Name:    Last Name:
Street:
City:   State:   Zip:
Phone:
E-Mail:

Deadline for submissions to be considered: September 13, 2012

Please fill in, print, sign, and turn in at our September 13, 2012 meeting, or send an email to PCohen@lafla.org.

SIGNATURE: ___________________________ DATE: _________________