Name of Applicant:
Name of person giving recommendation:
State how you have been associated with applicant:

Statement about character and achievements of applicant (Please use he/she and not applicant's name):

Please print out this form and sign and date below. 

Mail completed form to:
Merrick Foundation, Inc.
P.O. Box 206, Central City, NE 68826

 
____________________________________________              ______________
Signature                                                    ......................... Date



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