Hear for the Holidays Nomination Form Please


[PDF]Hear for the Holidays Nomination Form Please...

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Hear for the Holidays Nomination Form NOMINEE INFORMATION First Name:

Last Name:

Address or City of Residence: Home/Cell Phone: (

)

Email:

Occupation:

Employer:

School and Grade: Current Hearing Aid User?: Yes:

No:

One Ear:

Both Ears:

NOMINATING PARTY INFORMATION First Name: Home/Cell Phone: (

Last Name: )

Email:

Please explain below why you believe your nominee would benefit from the “Hear for the Holidays” giveaway from Doss Audiology. You may attach another page to complete your paragraph if necessary.

Doss Audiology may be in contact with you for additional information about the nominee. Selection is based on financial need, degree of hearing loss, community involvement, and communication difficulty. Please contact our office with additional questions. Doss Audiology & Hearing Center 5000 Schertz Parkway, Suite 300 Schertz, Texas 78154 210-819-5002

Doss Audiology & Hearing Center-Floresville 1605 US Hwy 181 N, Suite A Floresville, TX 78266 [email protected]

www.dossaudiology.com