FORM

2004 SUSAN B. ANTHONY AWARD

NOMINEE INFORMATION

NAME:

ADDRESS:

SUBMITTED BY

NAME:	ADDRESS:
PHONE:
EMAIL:

1. Please describe how the nominee has met the 5 listed criteria. If necessary, you may attach a single 8.5 x 11 sheet of paper.

a. Promoting awareness of, and political action for, woman's issues.

b. Provided services to women in crises.

c. Advancement of educational opportunities for women.

d. Development of grass roots leadership for the empowerment of women.

e. Lifelong or long-term activity not solely in the field of one's paid work or profession.

2. Please list the nominee's involvement in, and awards from, community and civic organizations.

3.Please write a brief paragraph giving your perspective why the nominee should receive the award.

Please return this form by February 13, 2004 to
JWHC
P.O. Box 903
Jackson MI, 49204
or Fax to 517.783.4651