2019 Stream Award Nomination Form

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* 1. Nominee's Contact Information

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Nominee's impact on women's health through direct health services, acquisition of new knowledge, dissemination of information, organizational leadership, etc.

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* 3. Nominee's record of productive collaborations

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* 4. Nominee's demonstration of exemplary leadership

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* 5. Nominee's brief biosketch highlighting accomplishments to date

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* 6. A web link for additional information about the nominee

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* 7. Nominator's Contact Information

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 8. Nominator's relationship with nominee

Supervisor

Peer/Colleague

Friend

Family Member

Other (please specify)

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* 9. Years nominator has known nominee

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* 10. Reference endorsing this nomination

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* 11. Nominee has been notified of his/her nomination and agrees to attend the award ceremony on Thursday, April 18, 2019

Yes

No

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* 12. Nominee agrees to provide a high-quality color photo for inclusion in the program for the Greater Houston Conference for Women (photo will be requested at a later date).

Yes

No

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* 13. Nominator agrees that, to the best of his/her knowledge, the information provided in this nomination form is accurate and up to date.

Yes

No