Nominee's Name:

Address:

City:

State:

Zip Code:

Home Phone:

Occupation/Title:

Work Phone:

Email:

Please give a brief description of the nominee's commitment to volunteerism in the JLM's focus areas of women and children at risk.

Volunteerism

How do you know about the work of the nominee?

Know Nominee's Work

Please list the organization(s) with which the nominee is affiliated provide any other information that you feel would be useful in assisting the selection committee in making its decision.

Additional Info

*Very Important - Please send Nominee’s resume, news articles and any other recent available documentation concerning the nominee. Please mail this supplemental material to HQ or email to Vicky Hucks.

Your Info

Proposer's Name:

Your Phone:

Your Email: