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ICW > ICW News > Press Releases > Indiana Commission for Women honors 2013 Torchbearers > Nomination Form Nomination Form

Step 1 – Nominee Information

Nominee’s Name:

Self-Employed? Yes No



Work Address:




Home Address:




Work Phone:

Home Phone:

Email Address:

Step 2 – Organization Submitting the Nomination


Contact Person Name:





Primary Phone:

Email Address:

Step 3 – Local people to notify about nomination:

Name of Nominee’s State Representative:

Name of Nominee’s State Senator:

Name of Nominee’s Mayor or other municipal leader:

Name of local newspaper:


Step 4 - Signatures of Nominating Organization


Additional Organizational Representative:

How did you hear about the Torchbearer Awards?

TV Newspaper Past Honoree Friend ICW Board Member Mailing Other (Please specify)

Step 5 – Nomination Criteria

Please answer the following questions thoroughly about the nominee by typing two to three paragraphs for each of the questions below. The Indiana Commission for Women and Council of Judges appreciate all of the information you submit and request that you provide as much information as concisely as possible. So, please keep each response to approximately 300px words.

Question 1: Briefly summarize why you believe the nominee should be awarded a Torchbearer Award.

Question 2: Describe the significant contributions made by this nominee to her community, to the state of Indiana or to her industry.

Question 3: Describe how the significant achievements made by this nominee have been accomplished under challenging circumstances and/or how these achievements can be an example for other Hoosier women.

Question 4: Explain how the achievements made by the nominee have made Indiana a better place in which to live, work and raise a family by removing barriers to equality.

Question 5: List the nominee's special honors, awards, special interests, professional affiliations, offices held, professional achievements, and volunteer experience.