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Application Form

Mr. Diabetes® Achievement Award™ 

Application Form

Be sure to provide the name and phone number of three (3) individuals who can verify your activities (or provide press clippings, original documents such as posters, invitations etc.)

 

Name of Nominee_______________________________________­­____________________ 

Address________________________________ City ________________State_____ Zip_____ 

Phone (   ) _____________ E-Mail Address_________________________________________

 

Date of Diabetes or Pre-Diabetes Diagnosis___________ Type 1 or Type 2 Diabetes _______________ 

Oral Medication/Insulin or Diet Control? _______________

 

Nominee’s Signature ______________________________

 (Parent or Guardian’s Signature required if under 18 years of age) 

 

Name of Nominator_____________________________ Relationship to Nominee_____________ 

Address________________________________City_________________State______Zip____ 

Phone (   ) ______________E-Mail Address_________________________________________

 

Nominator’s Signature_________________________________________________________

(Parent or Guardian’s Signature required if under 18 years of age) 

Date____________________________________________________________________

 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Verification Name (1) _________________________________ Relationship to Nominee __________ 

Address________________________________City_________________State______Zip ____ 

Phone (   ) ______________E-Mail Address_______________________________________

 

Verification Name (2) _________________________________ Relationship to Nominee __________ 

Address________________________________City_________________State______Zip ____ 

Phone (   ) ______________E-Mail Address_______________________________________

 

Verification Name (3) _________________________________ Relationship to Nominee __________ 

Address________________________________City_________________State______Zip ____ 

Phone (   ) ______________E-Mail Address_______________________________________ 

 

By signing this application, you indicate your consent for the Defeat Diabetes Foundation to contact you for more information. 

Completed Applications may be sent to: 

Mr. Diabetes® Achievement Award™ Administrator
Defeat Diabetes Foundation
501 150th Avenue North
Madeira Beach, FL 33708