2017 Stream Award Nomination Form Question Title * 1. Nominee's Contact Information Name Company Address Address 2 City/Town State/Province ZIP/Postal Code Email Address Phone Number Question Title * 2. Nominee's impact on women's health through direct health services, acquisition of new knowledge, dissemination of information, organizational leadership, etc. Question Title * 3. Nominee's record of productive collaborations Question Title * 4. Nominee's demonstration of exemplary leadership Question Title * 5. Nominee's brief biosketch highlighting accomplishments to date Question Title * 6. A web link for additional information about the nominee Question Title * 7. Nominator's Contact Information Name Company Address Address 2 City/Town State/Province ZIP/Postal Code Email Address Phone Number Question Title * 8. Nominator's relationship with nominee Supervisor Peer/Colleague Friend Family Member Other (please specify) Question Title * 9. Years nominator has known nominee Question Title * 10. Reference endorsing this nomination Question Title * 11. Nominee has been notified of his/her nomination and agrees to attend the award ceremony on Thursday, April 20, 2017 Yes No Question Title * 12. Nominee agrees to provide a high-quality color photo for inclusion in the program for the Greater Houston BE EXTRAORDINARY Conference for Women (photo will be requested at a later date). Yes No Question Title * 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 Submit