YWCA of Silicon Valley - Tribute to Women (TWIN)

Tribute to Women (TWIN) Honoree Nomination Form

Application Deadline for Nomination is Tuesday, November 30, 2010 by 5:00 pm

Instructions:

Before filling out this form, please read the Application Guidelines and Requirements.

Fill out this form with Nominee and Nominator information as requested.

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Nominee Information:
Please answer all of the following questions.

Nominee's Name:


First Name	MI*	Last Name
	(*if used)

Suffix

Other

Company:

Position / Title:

Bus. Mailing Address1:

Bus. Mailing Address2:

City, State, Zip:

Business Phone:

Ext: Fax:

E-mail:

Home Mailing Address:

Street Address / P.O. Box

City, State, Zip:

Home Phone:

Contact Person for Nominee:
Note: Admin. Asst./person responsible for follow-up details with Honoree.

Contact's Name:


First Name	MI	Last Name

Position / Title:

Bus. Mailing Address1:

Bus. Mailing Address2:

City, State, Zip:

Business Phone:

Ext: Fax:

E-mail:

Nominator:
Note: Must be CEO or highest-ranking local officer or director in company or division/business unit.

Nominator's Name:


First Name	MI	Last Name

Position / Title:

Bus. Mailing Address1:

Bus. Mailing Address2:

City, State, Zip:

Business Phone:

Ext: Fax:

E-mail:

I acknowledge the requirement to host a table at the event to recognize the company's Honoree and to support the fundraising activities and mission of the YWCA of Silicon Valley. Please note that there is a minimum donation of $2,500 per honoree.

Sponsor Contact:
Note: Responsible for all follow-up details for corporate sponsorship.

Name:


First Name	MI	Last Name

Position / Title:

Bus. Mailing Address1:

Bus. Mailing Address2:

City, State, Zip:

Business Phone:

Ext: Fax:

E-mail:

Nominee Profile:
Please answer all of the following questions as they pertain to the nomination criteria described in the Application Guidelines and Requirements. The selection committee will rely on this information in making its decision for selecting the final TWIN Honorees.

1-a. Statement of achievement from Nominator in 200 words* or less:

Describe your nominee’s significant contribution to the company during the 2009 calendar year in regards to the impact on the organization relative to its growth, profitability and innovation
Describe how the nominee has a significant share of the organization's annual budget and/or executive level responsibility for financial performance of the organization
Explain what separates this nominee from others as a leader in the company
Discuss any outstanding leadership qualities that your nominee routinely demonstrates and specifically how this person is a successful role model for other women transitioning into executive positions or how this nominee mentors/coaches women internally or externally from the organization

*Note: This statement is the MOST IMPORTANT CRITERIA the Selection Committee will use during the selection process.

Statement of
Achievement:
(200 words)

1-b. Statement of achievement from Nominator in 50 words* or less:

*Note: THIS STATEMENT WILL BE PRINTED IN THE EVENT PROGRAM BOOK (may be an excerpt from the 200 word statement of achievement or additional statement).

Statement of
Achievement:
(50 words)

2. List the three most critical responsibilities of nominee:

3. Number of management levels between the CEO/highest-ranking local officer in the company or division/business unit and the nominee:

1 2 3 4 5 or more

4. Nominee reports to:

Name:

Title:

5. Nominee's total years with company (The nominee must have been employed at current company for at least one year at time of nomination.):

1-5 yrs. 6-10 yrs. over 10 yrs.

6. Number total of local employees in the company:

1-100 101-500 501-2,000
2,001-10,000 greater than 10,000

7. Number of employees under nominee's management:

0 1-10 11-20
21-50 51-75 76-100
greater than 100

For Corporation, or Division/business unit

8. Does the Honoree have global responsibility: Yes No n/a

9. Percentage of total company budget nominee is responsible for:

0-25% 26-50% 51-75%
76-100%

For Corporation, or Unit/Division

10. Nominee's total operating budget: (Optional)

Company Profile:

11. Company Name (as it should appear in all publicity):

12. Organizational Profile (provide a description of your company in 50 words or less):
NOTE: Item 12 (Profile) will be printed in the Event Program.