Grand Rapids Business Journal 2012 "40 Under Forty" Nomination Form

1. Nominee information

Nominee photo and other supporting information, such as a résumé, must also be emailed to cvalade@geminipub.com by no later than 8/6/2012. Nominees must be under 40 years of age as of 6/30/12.

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* 1. Contact information:

Name: *

Company: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Email Address: *

Phone Number: *

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* 2. Age:

Date of birth:

Date

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* 3. More about the nominee:

Number of years lived in West Michigan:

Job title:

Industry:

College(s):

Experience living or working in another culture:

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* 4. Awards/Accomplishments/Honors:

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* 5. PROFESSIONAL board/council memberships:

Name of board #1:

Position held on board #1:

No. of years served on board #1:

Board #1 achievements:

Name of board #2:

Position held on board #2:

No. of years served on board #2:

Board #2 achievements:

Name of board #3:

Position held on board #3:

No. of years served on board #3:

Board #3 achievements:

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* 6. COMMUNITY board/council memberships:

Name of board #1:

Position held on board #1:

No. of years served on board #1:

Board #1 achievements:

Name of board #2:

Position held on board #2:

No. of years served on board #2:

Board #2 achievements:

Name of board #3:

Position held on board #3:

No. of years served on board #3:

Board #3 achievements:

Grand Rapids Business Journal 2012 "40 Under Forty" Nomination Form

1. Nominee information

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* 1. Contact information:

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* 2. Age:

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* 3. More about the nominee:

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* 4. Awards/Accomplishments/Honors:

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* 5. PROFESSIONAL board/council memberships:

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* 6. COMMUNITY board/council memberships:

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* 7. Other volunteer activities:

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* 8. Who is the biggest influence in your life?

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* 9. What was your biggest professional break?

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* 10. Of what accomplishment are you most proud?

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* 11. Why do you believe that you should be included in GRBJ's 2012 "40 Under Forty" class?