In order for us to create a web post to accompany your video interview, the following information is required. Please type the information in the boxes below EXACTLY as you wish for it to appear.  Please use a desktop or laptop to fill out the form. iPhones and iPads are not compatible with the form.

Award Winner's Name

Name of Current Employer

Job Title

Email Address

Professional Bio

The host will also ask you these questions during your 6-minute TV interview. Provide your answers to them in text below. They will be used in the web post that will accompany your interview video.

Q1: Who do you look up to for inspiration and mentorship?

Q2: What are the most important attributes of successful leaders today?

Q3: What one thing makes you most proud?

Q4: What’s the most important risk you took and why?

Submit 4-8 images that support your answers to the four questions above. Ideally, we will cut away to the photos during the interviews. If your photo file is larger than 50MB, email it directly to Angela Hager at ahager@nctv17.org.

Drop files here or
Max. file size: 256 MB.