Northern Maine General Hospital - Information Request

NMG Celebrates Its Centennial Year
MEMORY BOOK PROJECT
SUBMISSION FORM

Print & Return This Form To: (Or Submit Online Version Below)

NMG Central Office
Attn: Reynold Raymond, CEO
P.O. Box 310
Eagle Lake, Maine 04739

As part of its Centennial Celebration, NMG will be creating a book that tells the history of the agency through the eyes of those whose lives it has impacted. We will include statements collected from former and present employees, individuals we serve, community members, and friends of the agency. Statements provided will be collected into book form. The book will preserve memories about the agency and tell its history in a unique way.
If you would like to participate in the project, please fill out this form completely, either via e-mail or print and mail, and return to the address above by March 30, 2006.

        Title:

Name:      Address:
City:         State:
Zip Code:
Phone:       E-mail:
Relationship to NMG:
Please write your story, memory, or recollection here:

Please read and type your name inf the space provided before submitting:

I give permission for NMG to edit, reproduce, and sell the statement written above:

Date: