2023 Shaker Nomination Form

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For our annual Magic City Cocktail Challenge event, the American Cancer Society plans to recognize the talents and achievements of young professionals in the Birmingham area who have distinguished themselves in our community.

I nominate the following individual for recognition:

Nominee First and Last Name: *

Gender:

Age:

Nominee Occupation and Title: *

Company Affiliation: *

Address:

City:

State:

Zip:

Nominee Phone: *

Nominee Email: *

Best way to contact:

Phone

Clear selection

My name:

My phone:

My email:

How do you know nominee?

If nominating yourself, please type "SELF"

Connection to cancer?

If you would like to share the nominee's connection to or passion for cancer prevention/programs/research, we would love to know their "why!"

Any additional info you would like to share about the nominee's achievements or affiliations:

Feel free to link any online bios or articles relating to your nominee here:

Submit

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