Ludwig Community Benefit Nomination Form

Nominee Information

Name of Nominated MHA-Member Organization

Name of Program

Name of Key Contact Person For Program

Title

Organization

Address

Street Address Address Line 2 City State ZIP Code

Phone

Fax

Email(Required)

Name(Required)

First Last

Job Title(Required)

Organization(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Fax

Email(Required)

Program Overview(Required)

Statement Of Problem And Goal(Required)

Leadership Role(Required)

Program Design and Assessment(Required)

Sustainability(Required)

NOMINATIONS MUST BE RECEIVED BY THE MHA BY THE CLOSE OF BUSINESS FRIDAY, FEB. 19, 2021.

Any additional materials should be emailed to eleyko@mha.org.

Name

This field is for validation purposes and should be left unchanged.