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10th Annual Relay For Life Torch Run Nominations Do you know a cancer survivor, someone who mourns or someone who plays a significant role in the fight against cancer? What about yourself? Is there someone you carry a torch for who has been touched by cancer? Tell us the story and give that special someone the honor of being one of those to carry the torch to kick off the 2011 American Cancer Society Relay For Life of Defiance on June 24, 2011. Nominations due no later than April 29, 2011 Nominee: Nominated By: Name: ______________________________ Name: ______________________________ Address: __________________________ Address: __________________________ Phone: ____________________________ Phone: ____________________________ E-mail: ____________________________ E-mail: ____________________________ The Story: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Continue on reverse side, if needed Please contact Pat at 419 784-3734 with any questions about the Relay For Life Torch Run or the Relay For Life of Defiance. Visit us on line at American Cancer Society 888.227.6446 Those selected as torchbearers and their nominator will be notified by the 2011 Relay For Life committee. We may ask for permission to publish your story. No stories will be published without prior permission from both the nominee and the nominator.

Mail your nomination(s) to: Bruce and Pat Zachrich 1506 Dublin Ct. Defiance OH 43512 This event is sponsored by:

Torch Run Nomination Form DEFi 2011