* Required Fields   Information about you:     * Full Name:   Required (first/middle/last) * Sex:   Female Male Required * Date of Birth:   Required * Email Address:   Required Street Address:   * City:   Required * State:   AK AL AR AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY Required * Zip Code:   Required (format: XXXXX) * Home Phone:   Required (format: XXX-XXX-XXXX) * Work Phone:   Required (format: XXX-XXX-XXXX)   Information about your nominee:     * Category:   Leader Perseverance Mentor Defender Promise Required * Name of Nominee:    Required (first/middle/last) * Date of Birth:   Required * Email Address:   Required Street Address:   * City:   Required * State:   AK AL AR AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY Required * Zip Code:   Required (format: XXXXX) * County:   Adams Amite Clarke Copiah Covington Forrest Franklin George Greene Hancock Harrison Jackson Jasper Jefferson Davis Jones Lamar Lawrence Lincoln Marion Pearl River Perry Pike Simpson Smith Stone Walthall Wayne Wilkinson Required   * Home Phone:   Required (format: XXX-XXX-XXXX) * Work Phone:   Required (format: XXX-XXX-XXXX)   Judging for awards will be based solely on the information provided on this form. Please provide enough detail to help judges understand why they should select your nominee. Please print or type responses.   *1.) Please describe why you feel your nominee deserves a Strong Woman award. If possible, please provide specific accomplishments:   Required   *2.) Describe an incident involving your nominee in which something she did or said serves as the best illustration of who she is:   Required   *3.) In your opinion, what one word best describes your nominee?   Required

Please be aware that although we do everything possible to safeguard your information, email, by it's very nature, is not a secure form of communication and may possibly be accessed by those who are not the intended recipient. Please read our privacy statement about information transmitted over the Internet. Also, please know that information you provide via this nomination form will be shared with members of Wesley Medical Center’s Board of Trustees, Women’s Advisory Council and medical staff, along with other community leaders. Again, we strive to safeguard your private information and urge you not to share any information you want to keep confidential.