Women of distinction endorsement form
Return completed form to Diane Seridge @ jackredf40@gmail.com by September 1, 2017
NOMINEE INFORMATION
Nominee Name__________________________________________________
Nominee Address________________________________________________
Nominee phone #________________________________________________
Nominee e-mail_________________________________________________
Please check:
__Education __Business __Environment __Health/Medical Sciences __Non-Profit __Other_______ *Please attach a brief BIO supporting your nomination.
SUBMITTED BY
Name__________________________________________________________
Address________________________________________________________
Telephone #_____________________________________________________
E-mail__________________________________________________________
Your Signature___________________________________________________________
Date______________________________________________
