SINCE 1945 - ENSURING HIGH STANDARDS OF GOOD HORSEMANSHIP, SPORTSMANSHIP AND FRIENDSHIP

NEW HAMPSHIRE HORSE & TRAIL ASSOCIATION

SUSAN ALLEN MEMORIAL LESSON FUND

NOMINATION FORM

 

 

NAME OF NOMINEE  __________________________________________________________

 

ADDRESS  ____________________________________________________________________

 

                    ____________________________________________________________________

 

DATE OF BIRTH  ______________________________________________________________

 

NAME OF PARENT/GUARDIAN  ________________________________________________

 

ADDRESS  ___________________________________________________________________

                     If different than nominee

 

TELEPHONE _________________________ E-MAIL ________________________________

 

NOMINATED BY ______________________________________________________________

 

ADDRESS ____________________________________________________________________

 

TELEPHONE _________________________ E-MAIL _________________________________

 

RIDING INSTRUCTOR __________________________________________________________

 

FARM/STABLE NAME __________________________________________________________

 

ADDRESS _____________________________________________________________________

 

TELEPHONE ____________________________ E-MAIL _______________________________

 

WHY IS THIS PERSON DESERVING OF THE AWARD ?  _____________________________

 

_______________________________________________________________________________

 

_______________________________________________________________________________

 

_______________________________________________________________________________

 

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Mail completed form to :  JAMES ALLEN, 1062 PLEASANT ST., BARRE, MA  01005