2023 Influential Women Official Nomination Form

Nominations are due by Sept. 28th, 2023. Judges select winners based on merit, not number of nominations. Nominating someone multiple times will not improve their odds of being selected. Incomplete nomination forms will not be considered.

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* 1. Nominee Contact Information

Name *

Company *

Address

Address 2

City

State

ZIP

Email Address *

Phone Number *

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* 2. Job Title

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* 3. Field (i.e. Healthcare, STEM, Arts, etc.)

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* 4. County

Adams

Allen

Defiance

DeKalb

Elkhart

Huntington

LaGrange

Noble

Paulding

Steuben

Van Wert

Wabash

Wells

Whitley

Williams

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* 5. Career Based Achievements:
(Please provide as much information about the nominee's work history and career achievements for consideration. It's okay if you don't have all the details, but please be specific. Judges will use this information when deciding who to award. )

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* 6. Community Based Achievements
(Please provide information about the nominee's work in the community or professional organizations. Explain how he or she makes a difference. It's okay if you don't have all the details, but please be specific. Judges will use this information when deciding who to award.)

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* 7. Anything else the judges should know:

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* 8. Nominator Contact Information

Name *

Company *

Address

Address 2

City

State

ZIP

Email Address *

Phone Number *

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* 9. Relationship to nominee (Spouse, coworker, boss, etc.)