The Potato Association of America
HONORARY LIFE MEMBERSHIP NOMINATION FORM

   NOMINEE'S NAME:
  ADDRESS:


   PHONE:                                        FAX:                                     E-MAIL:

  EDUCATION:

 

 

 

 

  CAREER HIGHLIGHTS:

 

 

 

 

  PARTICIPATION IN THE POTATO ASSOCIATION OF AMERICA:

 

 

 

  

   Nominator: [Please Print] ________________________________________________________

   Signature:________________________________________________________________
   Address:

 

   Nomination Supporters (5 including nominator: Include name, address, phone number & e-mail)

Name [Nominator]

 

Address Phone No. & E-mail
 

 

    
 

 

    
 

 

    
 

 

    

Send to:  Sam Thornton, Syngenta Crop Protection, Inc.
1767 Road F.5 NE, Moses Lake, WA 98837 USA
sam.thornton@syngenta.com