Nomination Form

SALEM COUNTY COMMISSION ON WOMEN
c/o Office of Clerk of the Board
94 Market Street, Salem, NJ 08079

WOMEN OF ACHIEVEMENT NOMINATION FORM

Please print out and complete the information below, and return to the Commission by December 08, 2003. You will be notified if your nominee will be honored at the Annual Luncheon on April 03, 2004. If your nominee is not chosen, please nominate her again next year. All nominees receive a letter acknowledging their contributions to Salem County. --Salem County Commission on Women

Nominator’s Name______________________________________________________

Nominator’s Address____________________________________________________

Nominator’s Phone Number ______________________________________________

Nominator’s E-Mail Address ______________________________________________

Nominee’s Name_______________________________________________________

Nominee’s Address______________________________________________________

Nominee’s Phone Number________________________________________________

Nominee’s E-Mail Address ________________________________________________

DIRECTIONS:

The nominee must reside in Salem County

The nominee’s name should NOT appear anywhere except on the front page of this form

Applications must be received no later than December 08, 2003.

Please list as many accomplishments as possible. DO NOT use narrative. DO NOT use additional paper.

Failure to follow directions completely will result in application being disqualified.

AREA 1: EDUCATION/CAREER

My nominee has completed her education (high school diploma/GED; college; graduate school), or is continuing to advance her education. Please list.

_________________ _________________ _________________

My nominee resides in Salem County. Please list how long and where.

_________________ _________________ _________________

My nominee maintains organizational affiliations (membership in alumni associations, professional associations, church groups, etc.) Please list.

_________________ _________________ _________________

My nominee has received special awards (educational awards, employment awards, etc.) Please list.

_________________ _________________ _________________

AREA 2: COMMUNITY SERVICE/PERSONAL DEVELOPMENT

1. My nominee volunteers to charitable organizations in her community (hospital/nursing home, fire/ambulance, auxiliary, "Meals On Wheels", churches, etc.) Please list.

_________________ _________________ _________________

2. My nominee keeps herself busy with personal interests ("hands-on" hobbies, pets, gardening, etc.) Please list.

_________________ _________________ _________________

3. My nominee donates time or resources to other organizations (public or private, educational, social, etc.) Please list.

_________________ _________________ _________________

4. My nominee has overcome personal obstacles, disability, personal loss, illness, or other special situation that has required her strength, courage, or skill. Please list.

_________________ _________________ _________________

AREA 3: ADDITIONAL INFORMATION

Please indicate your relationship to the nominee (check only one):

________I am related to the nominee (spouse, child/grandchild, sibling, etc.)

________I work with the nominee (employer/supervisor, co-worker, etc.)

________I am a friend of the nominee

________The nominee has helped me (through volunteer experience, through employment, as a neighbor, etc.)

Submit completed applications to:
Salem County Commission on Women
c/o Office of Clerk of the Board
94 Market Street
Salem, NJ 08079