Champions of Change Awards Nomination 2021

Champions of Change Awards 2021

Thank you for supporting the mentorship and empowerment of women in Allen County! Please notify your nominee before submitting this form. Personal nominee and nominator information will NOT be shared with the selection committee. We will only share the comments in the Questions portion below.
Nominee Information

This section will not be shared with selection committee.
Name *

First Name Last Name
Gender *
Employer *
Title *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *

Area Code Phone Number
Nominator Information

This section will not be shared with selection committee.
Name *

First Name Last Name
Employer *
Title *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *

Area Code Phone Number
Nomination Questions

Your responses to the following section will be used by the selection committee to evaluate your nominee. Please do not use the nominee's name when answering questions, only pronouns.
How has the nominee demonstrated leadership, passion, and commitment to our community? *

0/400
How has the nominee served as a role model and/or mentor in the lives of others? Please provide specific examples. *

0/400
What has the nominee done to inspire women to succeed? Please provide specific examples. *

0/400
How has the nominee made Allen County a better place to live, work, and play? *

0/400
Supporting Materials

Please attach a high-resolution photo and short (250 words) bio of the nominee. Both can be obtained from the nominee, if necessary. This information will not be shared with the selection committee.
Please provide a brief bio of the nominee. *

0/250
Upload a high-resolution headshot photo of the nominee here. *

Browse Files

Cancel of
I CERTIFY THAT ALL STATEMENTS OR INFORMATION I HAVE PROVIDED ABOVE ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. ANY DELIBERATE MISREPRESENTATION FOUND IN THIS NOMINATION MAY BE CAUSE FOR THE DISMISSAL OF THIS NOMINATION AND MAY PROHIBIT ME FROM RECOMMENDATION AGAIN IN THE FUTURE.
Nominator's Signature

Clear
Name of Nominator *

First Name Last Name
Date Signed by Nominator *
mm/dd/yyyy
Should be Empty:

Champions of Change Awards 2021

Nominee Information

Nominator Information

Nomination Questions

Supporting Materials