Nominations

OVERCOMER'S AWARD-NOMIMEES

You may nominate someone from your congregation, a relative, friend or neighbor to be considered for one of the four awards
to be presented during our 20th. Anniversary festivities. Each Nominee must have a sposor and a donation of $50.00 must be submitted
by Friday December 2, 2011 for the nomination to be concidered. All checks or Money Orders must be made out to:
CHRONIC PAIN SUPPORT GROUP, INC., for Over-Comer's/Nominee sponsorship. Checks should be mailed to:

CPSG, INC
P.O. BOX 503
LEXINGTON, KENTUCKY, 40588-0503

Your Name

Your Email

Your Address

Your City State Zip Code

Your Phone Numbers

Please choose from one of the following 5 catagories

PHYSICAL CHALLENGES (Physical Hadicap, Scars, Sickness, or Pain)
MENTAL CHALLENGES (Mental, Brain Tumor, Setback, i.e. Chemotherapy, Radiation, etc.)
EMOTIONAL CHALLENGES (Emotional Pain, Employment, a Great Loss, Death or Accident)
OVERCOMER OF THE YEAR (Overcame all of the above,and remained productive in 2011)
LIFETIME ACHIEVEMENT AWARD (Overcame all of the above & remained productive during their life)

Name of Overcomer

Address of Overcomer

City State Zip Code

Overcomer's Phone Number

Description of why you are nominating the individual

Please type a brief description in the box below