Information concerning the person proposed for mark of honour:
Date of Birth:
Zip code and city:
Details of the person who suggests that the above-mentioned person receives a medal:
Place and date:
Name of the person proposed for mark of honour:
1. Has been active in the profession during the period:
2. Held positions in the following periods:
3. Special efforts:
4. Other public service of importance:
Responsible for the accuracy of the given information:
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