* 1. Nominee's Contact Information

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

* 3. Nominee's record of productive collaborations

* 4. Nominee's demonstration of exemplary leadership

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

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

* 7. Nominator's Contact Information

* 8. Nominator's relationship with nominee

* 9. Years nominator has known nominee

* 10. Reference endorsing this nomination

* 11. Nominee has been notified of his/her nomination and agrees to attend the award ceremony on Wednesday, April 25, 2018

* 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).

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

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