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2013 Take The Lead Awards Nomination Form


Deadline for Philadelphia nominations is October 8th at 5pm.

Deadline for Berks and Lehigh Valley is October 19th at 5pm.

Please contact Denise Sullivan with any questions at 215-564-2030 ext. 1036 or dsullivan@gsep.org.


Nominator's First Name

 

Nominator's Last Name

 

Nominator's Title

  

Nominator's Company/Organization Affiliation
 

Nominator's Preferred Mailing Address

  

City
 

State

  

Zip Code
 

Nominator's Email Address

  

Nominator's Primary Phone
 
 

Nominee First Name

  

Nominee Last Name
 

Nominee Title

  

Nominee Company/Organization Affiliation

 

Nominee Preferred Mailing Address

  

Nominee City
 

Nominee State

  

Nominee Zip Code
 

Nominee Email

  

Nominee Phone
 
Nominee's Educational Background:  

Was the nominee a Girl Scout in her youth?    Yes   No   I Don't Know  

Please describe nominee's current profession and job responsibilities: 
Describe nominee's volunteer, philanthropic, or other relevant activities:
Why is the nominee a role model for girls and young women?
Describe the nominee's civic and/or professional affiliations and offices or positions held within those organizations:
In what ways does the candidate exemplify the Girl Scout mission of living with courage, confidence, and character to make the world a better place?
Describe nominee's awards and achievements:  
Additional information to support the nominee's qualifications:
Optional Attachment: (Resume or CV; MS Word or PDF Only)
 
 
Submit