Deborah Sampson Award Official Nomination Form

Deborah Sampson Award—Official Nomination Form Deadline: October 14, 2016

Name of Nominee: ______Nominee’s Address: ______Nominee’s Telephone & Email Address: ______Nominee’s Signature: ______(Nominee must verify that the information provided is accurate.) ********************************************************************* Please fill out the information below as completely as possible. You may attach additional sheets as necessary. Typed nominations are preferred. Please note that the more information you add the better the chances of having a strong candidate. ********************************************************************* A Massachusetts woman is eligible for this award if she served active duty in the U.S. military, Reserves, or National Guard. Military service will be rated as more important than other criteria in the award selection process.

1. Provide an overview of the nominee’s military service, awards, and pioneering efforts for women in the military. 2. Describe any personal sacrifices or hardships the nominee endured in order to serve in the military. 3. Please specify the nominee’s accomplishments toward the enhancement of the lives of female veterans through community service and participation in veterans’ organizations. 4. Why does this nominee merit special recognition as an Outstanding Woman Veteran? Please be specific.

Nominator’s Name: ______Nominator’s Email: ______

Nominator’s Telephone & Address: ______

Return nomination form to: Women Veterans’ Network 600 Washington St., 7th Floor Boston, MA 02111 OR fax: 617-210-5755 *NOTE: All nominees and nominators are encouraged to attend the “Women Veterans Appreciation Day” ceremony on Friday, November 4, 2016 at 11:00 AM, in the State House. For more information call 617-210- 5958 or email: [email protected]