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  • 7/29/2019 2013 New York State Senate "Women of Distinction" Nomination Form

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    SENATOR PATTY RITCHIE2013 WOMEN OF DISTINCTION NOMINATION FORM

    Name and Address of Nominee:

    __________________________________________________________________________________________________

    __________________________________________________________________________________________________

    Name of Nominating Individual:_________________________________________________________________________

    Organization and Title of Nominating Individual:____________________________________________________________

    Address:___________________________________________________________________________________________

    Telephone:__________________________Fax:_________________________Email:______________________________

    Please provide the following nominee information:

    Birthdate:______________________________Place of Birth:_________________________________________________

    High School:_______________________________________College:__________________________________________

    Other Degrees and/or Certifications:_____________________________________________________________________

    Academic Awards or Achievements:_____________________________________________________________________

    __________________________________________________________________________________________________

    __________________________________________________________________________________________________

    Community, Civic or Business Awards and Recognitions:

    __________________________________________________________________________________________________

    __________________________________________________________________________________________________

    __________________________________________________________________________________________________

  • 7/29/2019 2013 New York State Senate "Women of Distinction" Nomination Form

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    Past & Present Community/Civic Involvement:

    __________________________________________________________________________________________________

    __________________________________________________________________________________________________

    __________________________________________________________________________________________________

    Volunteer Service:

    __________________________________________________________________________________________________

    __________________________________________________________________________________________________

    Military Service:_____________________________________________________________________________________

    Present Occupation:__________________________________________________________________________________

    Relevant Past Occupations:____________________________________________________________________________

    Hobbies and Interests:________________________________________________________________________________

    Marital Status:______________________________________Children:_________________________________________

    Who or what were your nominees major influences?

    __________________________________________________________________________________________________

    __________________________________________________________________________________________________

    __________________________________________________________________________________________________

    What, if any, obstacles has your nominee overcome?

    __________________________________________________________________________________________________

    __________________________________________________________________________________________________

    __________________________________________________________________________________________________

    What do you think has been your nominees major accomplishment (s)?

    __________________________________________________________________________________________________

    __________________________________________________________________________________________________

    __________________________________________________________________________________________________

    ***Please email form [email protected] fax to (315) 782-6357***

    mailto:[email protected]:[email protected]:[email protected]:[email protected]

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