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2015 Women of Excellence Nomination Form

Nominee Information

Name of Nominee:

Age:

Title/Position:

Company/Affiliation:

Years in Industry:

Nominee Contact Information

Address:

City:

State:

–Please Select–

MI

AL

AK

AZ

AR

CA

CO

CT

DE

DC

FL

GA

HI

ID

IL

IN

IA

KS

KY

LA

ME

MD

MA

MN

MS

MO

MT

NE

NV

NH

NJ

NM

NY

NC

ND

OH

OK

OR

PA

PR

RI

SC

SD

TN

TX

UT

VT

VA

WA

WV

WI

WY

Zip Code:

Day Phone:

Evening Phone:

Fax Number

Email Address:

Criteria

Check All That Apply:

Proven success within her profession/industry.

Positive role model whose contributions encourage others.

Active in community service or organizational involvement.

Questions To Be Completed

Describe the specific accomplishments that demonstrate the nominee’s excellence.

Describe the nominee’s community service activity or organizational involvement.

How has the nominee mentored others?

Nominator’s Contact Information

Name:

Title/Position:

Company/Organization:

Address:

City:

State:

–Please Select–

MI

AL

AK

AZ

AR

CA

CO

CT

DE

DC

FL

GA

HI

ID

IL

IN

IA

KS

KY

LA

ME

MD

MA

MN

MS

MO

MT

NE

NV

NH

NJ

NM

NY

NC

ND

OH

OK

OR

PA

PR

RI

SC

SD

TN

TX

UT

VT

VA

WA

WV

WI

WY

Zip Code:

Day Phone:

Evening Phone:

Fax Number

Email Address:

Enter the code

 

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Women of Excellence 2018!
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