Mom of the Moment Nomination Form

If you would like to nominate an amazing Mom, please complete the form below.

Your Name*:
Your E-Mail*:
Your Phone*:
Your Relationship to Nominee*:
Name of Nominee*:
Nominee's Phone*:
Nominee's Email:
Nominee's Age:
Nominee's City*:
Nominee's Occupation*:
Nominee's Children & Ages:
Tell us why she should
be Mom of the Moment*:


phone/fax: 605-716-5696
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