Nominatee Name *

First Name

Last Name

Nominee Phone

(###)

###

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Nominee Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Nominator Name *

First Name

Last Name

Nominator Phone *

(###)

###

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Nominator Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Declaration *

As the nominator, I hereby certify that the information contained in this nomination form is true & correct and I authorize release of this information to the Leading Ladies Committee to publicize in any manner they may consider appropriate.

YES