DATE: ______________

NAME:_________________________________________________________

ADDRESS:______________________________________________________

CITY: ____________________STATE/PROV:______ZIP/POSTAL CODE:____

PHONE: ________________FAX:_______________ E-MAIL ______________

NUMBER OF YEARS OF PARTICIPATION AS:

PLAYER_____________MANAGER___________ADMINISTRATOR___________

OFFICIAL_____________AREA OF PARTICIPATION_____________________

SUBMITTED BY:_________________________________________________

ADDRESS:______________________________________________________

CITY______________________STATE/PROV:_______ZIP/POSTAL CODE:__

PHONE:________________FAX:_____________E-MAIL:_________________

DATE OF BIRTH OF NOMINEE: _____________________________________

DEADLINE IS MAY 1. PLEASE ATTACH A RESUME OF YOUR NOMINEE FOR THE I.S.C. HALL OF FAME ON A SEPARATE PAGE. SEND ALONG WITH THIS FORM TO:

ROBERT GRAY, CHAIRMAN
I.S.C. HALL OF FAME COMMITTEE
2843 Trotters Trail
Wetumpka, AL 36093

PHONE:  334-567-9797
E-MAIL:   RGray77271@aol.com