PERSONAL INFORMATION (for Academy files only; please fill out completely)

Home Address
City
State	New York	Zip
Phone		Fax

On a separate sheet of paper, describe how your candidate meets one or more the following criteria (email as a word doc attachment to ywcaadmin@cnymail.com or fax to (315) 424-1249)

1. Participates in programs to promote and embrace diversity
2. Supports opportunities for women’s growth & leadership
3. Embodies the spirit of peace, justice, freedom and dignity
4. Works toward the elimination of racism

STATEMENT OF ACHIEVEMENT DESCRIBING IMPACT ON COMPANY, ORGANIZATION, COLLEAGUES AND COMMUNITY. (Please refrain from writing in the first person. This statement will be published in the Day of Commitment program. Please limit statement to 50 words or less).

The following individuals will receive notification of your candidate’s selection. Please type or print the full name, title and address of each individual.

CANDIDATE REPORTS TO:

Name
Title
Company/Organization
Street Address
City
State	New York	Zip
Phone		Fax

CHIEF EXECUTIVE OFFICER (if different from above):

Name
Title
Company/Organization
Street Address
City
State	New York	Zip
Phone		Fax

SUBMITTED BY (if different from above):

Name
Title
Company/Organization
Street Address
City
State	New York	Zip
Phone		Fax

COMPANY/ORGANIZATION CONTACT PERSON
Please note: The contact person will be the primary person responsible for providing the completed application, table arrangements and ticketing for the April luncheon.

Name
Title
Company/Organization
Street Address
City
State	New York	Zip
Phone		Fax