Women Making a Difference Nominations

Thank you in advance for sharing with us.

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* 1. Name of woman you are nominating, including first, last, or other names she may have used.

First name.

Last name.

Maiden name if applicable.

Any nickname or other names she was known by.

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* 2. Her date of birth if known.

Date / Time

Date

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* 3. Is the woman you are nominating still living?

Yes

I don't know.

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* 4. Date of death if applicable.

Date / Time

Date

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* 5. Her spouse (if applicable).

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* 6. The names of any children (if applicable).

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* 7. Please tell us why you feel this woman is a good candidate as a "Woman Making a Difference." Please share details of her contributions to Vinton and the surrounding areas and how it positively impacted others. Include dates and specific details if possible!

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* 8. Please tell us how you know or learned of this woman.

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* 9. Your contact information.

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 10. May we use your name when sharing information about the person you nominated?

Yes

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* 11. Please upload a photograph if you have one to share. Please use your nominee's name as the file name.

Click choose file and locate the photo on your computer. You may also email photos to info@vintonia.org. Please specify Women Making a Difference in the subject line.

GIF, JPEG, JPG, PNG file types only.

Choose File