Fill out form Online or print out and fax

2003 REAR ADMIRAL HALERT C. SHEPHEARD AWARD FOR ACHIEVEMENT IN MERCHANT MARINE SAFETY
NOMINEE:
Name:
Affiliation:
Position/Job Title:
Address:
Telephone:
Description of Nominee’s Achievements in Merchant Marine Safety:
(Please use additional pages/attachments as appropriate.)
NOMINATOR
Name:
Affiliation:
Position/Job Title:
Address:
Telephone:
Date:	Signature:

Please return form and any additional supporting materials by February 14, 2004 to:
“ Shep” Award Committee
Chamber of Shipping of America
1730 M Street, NW, Suite 407
Washington, DC 20036-4517