WOMEN LEADERS IN MEDICINE NOMINATION FORM

Your Name:
Your Email:
Your Phone:
Your School:

If your nominee is chosen, would you like to conduct the interview? This choice does not affect whether the nominee will be chosen. We will conduct the interview if you decline.

Yes No

If yes, do you agree to follow the interview guidelines below?

Yes No

Interview Guidelines
Interviews will be conducted with the 20 selected nominees. Should you choose to interview someone that you nominate, we will notify you when and if that nominee has been selected for interviewing. We will make this selection in November or December, and all interviews must be completed by February 1. Any interviews that have not been received by February 1 will be disqualified. Interviews may be conducted in person, over email, or over the phone, but if conducted in person or over the phone, you must maintain adequate notes to provide quotes and background stories - these interviews will not be editorialized.

Nominee's Name:
Nominee's Title:
Nominee's Affiliation (Company, School, etc):

Please briefly describe your reasons for nominating this person: (250 words or less)

Please briefly describe this person's major accomplishments or inspirational story: (250 words or less)

Please use this space to provide any other information you want us to know about this nominee: (250 words)