2013 Salute to Women AwardsNomination Form

Instructions: Please complete the nomination form. The form must be submitted no later than February 15, 2013. The nominator must select an award category for which the nominee should be considered. The nominator may select more than one category for the nominee. Please note that the Selection Committee reserves the right to place nominees in a category other than that which they are nominated. Please respond with N/A if the question does not apply.

1. Nominee Information: *This question is required.

Nominee's First Name: *This question is required.

Nominee's Last Name: *This question is required.

Job Title: *This question is required.

Organization/Company: *This question is required.

Street Address: *This question is required.

City: *This question is required.

State: *This question is required.

Zip Code: *This question is required.

Work Phone: *This question is required.

Home Phone: *This question is required.

Cell Phone: *This question is required.

Email: *This question is required.

You may nominate one person per form. Please select the category or categories for the person you are nominating from the list below.

2. Award Categories *This question is required.

3. In what capacity do you know the nominee? *This question is required.

4. Biography of nominee (100 words or less) *This question is required.

5. Professional Background *This question is required.

6. Honors/Awards *This question is required.

7. Boards/Committees *This question is required.

8. Why have you selected this individual for this category? Please note this for each category that you have checked for this nominee. *This question is required.

9. Briefly describe the nominee's community involvement, volunteer activities, impact on social, educational, economic and/or cultural spheres in the City of Alexandria. *This question is required.

10. Describe how the nominee has made the community a better place for women and/or girls in Alexandria, including any programs, projects, or other efforts that impact women and/or girls. *This question is required.

11. Briefly describe the nominee's ability to mentor, serve as a role model, or encourage women and girls. Explain how this individual is an inspiration to women and girls. *This question is required.

12. Additional comments that you deem relevant to the nominee's application (Not Required). *This question is required.

13. Nominator's Contact Information

First Name: *This question is required.

Last Name: *This question is required.

Affiliation/Association to Nominee: *This question is required.

I am submitting a nomination in behalf of a company or organization

Yes

Name of Company/Organization: *This question is required.