Nominate

Please complete the information below to the best of your ability. There are no “wrong answers.” If you need assistance in completing the nomination form, please contact Fresh New Start at (850) 583-0085. Required fields must be completed in order to submit the form.

Nominator Information

Name (required)

Email (required)

Phone (required)


Home Work Mobile 

Mailing Address 1 (required)

Mailing Address 2

Relationship to Nominee (required)

How did you hear about FNS? (required)

Please provide a brief narrative about the nominee and the journey that resulted in her widowhood. Also include what has led you to make this nomination. (required)


Nominee Information

Name (required)

Email (required)

Phone (required)


Home Work Mobile 

Mailing Address 1 (required)

Mailing Address 2

Birthdate

Wedding Anniversary

Approximate Age at Spouse's Death

Number of Children

Employed
Yes No 

If yes, where?


Deceased Spouse Information

Name (required)

Type of Cancer

Duration of Illness (Diagnosis to Passing)

Date of Spouse's Death (required)

Web Link to Obituary


By checking this box, the nominator understands all information above to be accurate, and also understands this submission in no way constitutes the awarding of a Renewal Trip by Fresh New Start. Nominator has also read the minimum requirements, found here, the nominee must meet for eligibility, and believes the woman nominated meets the criteria contained therein. This form is merely the first step in the nomination process.