Role Model Nomination Form
BAD INFLUENCE
Inciting bad attitudes for a better America

The most important single influence in the life of a person is another person ... who is worthy of emulation.
Paul D. Shafer
(This will be used to inform the nominee of his/her selection and verify the information offered. It will not be shared with anyone.)
Your name and city and state of residence will be used after the nominee's listing like this: "Nominated by Jane Doe of Anywhere, Any State." Your contact info will be used to verify your nomination. It will not be shared with anyone.