Nomination Form

NOMINATOR INFORMATION:

Name *

Company Name *

Job Title *

Mailing Address *

Address Line 1

City

State

Zip Code

Email *

Cell Phone *

Work Phone

NOMINEE INFORMATION:

Name *

Occupation *

Company Name *

Job Title *

Executive Assistant/Assistant’s Name

Executive Assistant's Email

Executive Assistant's Phone

Area of STEAM emphasis

Employer

Work Address

Address Line 1

City

State

Zip Code

Home Address *

Address Line 1

City

State

Zip Code

Cell Phone *

Work Phone

Ethnicity

Highest Level of Education

Email *

DESCRIBE SPECIFIC EXAMPLES OF THE NOMINEE’S CONTRIBUTIONS TO HER FIELD OF ENDEAVOR, PROFESSIONAL ACCOMPLISHMENTS, RECOGNITIONS AND AWARDS *

DESCRIBE THE NOMINEE’S COMMITMENT TO DIVERSITY IN STEAM AND TO INSPIRING AND MENTORING OTHERS IN THE WORKPLACE AND THE COMMUNITY. LIST PROGRAMS AND NON-PROFIT INVOLVEMENT *

SHARE WAYS IN WHICH THE NOMINEE VOLUNTEERS AND MENTORS YOUNG GIRLS, PARTICULARLY YOUNG GIRLS OF COLOR. PLEASE SPECIFY ANY MENTORSHIP PROGRAMS THEY CREATED AND/OR ARE INVOLVED WITH *

PLEASE LIST ADDITIONAL INFORMATION TO CONSIDER INCLUDING ORGANIZATIONS THE NOMINEE IS AFFILIATED WITH, BOARDS SERVED ON AND PROGRAMS THEY HAVE INITIATED AT WORK OR IN THE COMMUNITY *

UPLOAD FILES

PLEASE INCLUDE UP TO (2) RECOMMENDATION LETTERS (.pdf) *

Click or drag files to this area to upload. You can upload up to 2 files.

PLEASE INCLUDE THE NOMINEE’S BIO OR CURRICULUM VITAE (.pdf) *

Click or drag a file to this area to upload.

UPLOAD NOMINEE’S PHOTO (.jpg or .png) *

Click or drag a file to this area to upload.

WOMEN WHO STEAM NOMINATION FORMS MUST BE SUBMITTED BY 11:59PM TUESDAY, MARCH 29, 2022 CST.

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