ICMCP®Annual Conference
“The Diversity Gap: From Obstacles to Opportunities”
Minority Educator of the YearNominationForm
Nominationsubmission period January 23 – February 15, 2017

NOMINEECONTACTINFORMATION

Please listname,title and company/organization name as you wouldlike toseein all printmaterials.

(Includephoneticpronunciation)

Data Fields with AsteriskAre Required / EnterDataIn ThisColumn
FirstName*
LastName*
Title*
Company/Organization Name*(62characterlimit)
Mailing Address*(No POBoxes)
City*
State*
Zip*
OfficePhone*(Includearea codeand extension)
MobilePhone(Includeareacode)
Email*
Assistant'sName
Assistant'sPhone(Includeareacode)
Assistant'sEmail
LinkedIn profileURL
Twitterhandle

NOMINATORCONTACTINFORMATION

Data Fieldswith AsteriskAre Required / EnterDataIn ThisColumn
NameofOfficialNominator*(ifdifferentthanNomineeInformation above)
Title*
CompanyName*
Address*
City*
State*
Zip*
OfficePhone*(Includeareacode)
MobilePhone(Includeareacode)
Email*

PRIMARYCONTACTCONCERNINGTHISNOMINATIONFORM

Data Fields with AsteriskAre Required / EnterDataIn ThisColumn
NameofPrimary ContactPerson regarding thisNomination Form*
Title*(CompleteremainingifdifferentfromNomineeor Nominatorcontactinformation)
CompanyName*
Email*
OfficePhone*(Includeareacode)
MobilePhone(Includeareacode)

PUBLICRELATIONSCONTACTFORTHISNOMINATIONFORM

Data Fields with AsteriskAre Required / EnterDataIn ThisColumn
NameofPRContact(ifapplicable)
CompanyName
Title
Address
City
State
Zip
OfficePhone*
MobilePhone(Includeareacode)
Email*

EXECUTIVENOMINATIONQUESTIONS

Nominee’sBio: Pleaselimitthelength to 300wordsorless.

Company/OrganizationGeneralInformation

1.Whatisthecompany’s/organization’sURL?

2.Provideabriefdescriptionof thecompanyororganization’sproductsorservices.

3.Whatisthetotalrevenueofthecompany/organization?

Lessthan$500M

$500M-$1B

$1B-50B

$50-100B__Greaterthan$100B

4.Whatisthetotalnumberofemployeesin thecompany/organization?

Lessthan10K

10K-50K

50K-100K__Greaterthan100K

5.Pleaseindicatethecompany’s/organization’sindustry.

AgricultureandMining

BusinessServices

Computersand Electronics

ConsumerServices

Mediaand Entertainment

Non-profit

Other(pleaseindicate:)

RealEstateand Construction

Education

Energyand Utilities__FinancialServices

Government

Retail

Softwareand Internet

Telecommunications

Transportation and Storage

Healthcare,Pharmaceuticalsand BiotechTravel,Recreation and Leisure

Manufacturing

Wholesaleand Distribution

6.Doescompany/organization haveanationalora globalpresence?

National__Global

Company/OrganizationInformation Security DepartmentInformation

1.WhatisthetotalannualbudgetforInformation Security?

Lessthan$1M

$1-25M

$25-50MXXMorethan$50M

2.WhatpercentageoftheIT budgetdoesthisamountrepresent?5%

3.Howmany employeesarein theInformation SecurityDepartment? (Pleaseindicateforboth US andworldwide)

0-10

10-30

30-75__150 ormore

75-150

4.IstheInformation Security Departmenta partoftheITorganization?YesIf not, pleasesharewhich department.

A.Major Efforts & Accomplishments

An educator can help in many ways. Please select 3 of the following 4educator categories most relevant to your efforts and follow the instructions for the corresponding questions on the next two pages. You may cite relevant supporting documents as applicable.

Note: The term “minority entrepreneurs” encompasses all stages of business ownership, including pre-startup.

  1. SUPPORTER | Raising awareness and advancing opportunities

Examples:

•Advocacy of the creation of new opportunities or new resources benefiting minority cybersecurity students

•Advocacy of policies, practices, legislation, etc. benefiting minority cybersecurity students

•Community outreach to increase public awareness and support of minority cybersecurity students

•Active participation in relevant organizations on behalf of minority cybersecurity students

  1. ADVISER | Providing education, training and/or mentorship

Examples:

•Cybersecuritytraining and/or counseling provided to minority students (including “behind-the-scenes” involvement, such as hosting classes)

•Mentorship of minority cybersecurity students

•Specific technical assistance provided to minority cybersecuritystudents (e.g. financial advice, market research assistance, etc.)

  1. FACILITATOR | Developing connections to resources and opportunities

Examples:

•Organization or growth of business-to-business networks (formal or informal) for minority cybersecurity students in order to help foster new business opportunities and relationships

•Formation of strategic alliances with non-profit organizations, government agencies, other businesses, etc. to help minority cybersecurity students access new training resources or employment opportunities

•Connecting minority cybersecurity students to existing business resources and/oremployment opportunities

  1. INITIATOR | Creating programs and resources

Examples:

•Creation of new resources benefiting minority cybersecurity students

•Development of new programs for minority cybersecurity students

The examples given for the above categories are intended as a guide only. Your own efforts and services may or may not be similar.

SUPPORTER

Describe your efforts/actions raising awareness of the needs of minority cybersecurity studentsand/or advancing new policies, opportunities, etc. What are your specific accomplishments and what impact have those accomplishments had on the minoritycybersecuritybusiness community?

ADVISER

Describe your efforts to educate, advise, assist, mentor, etc. minority cybersecurity students. What is the approximate total number of minority cybersecuritystudentseducated/assisted/mentored, and what are some significant results (such as certificates or degrees achieved,skillsetimproved, etc.)?

FACILITATOR

Describe your efforts to develop/grow networks, form strategic alliances and/or otherwise connect minoritycybersecurity students to existing resources or employment opportunities. What are your specific accomplishments and how have these accomplishments benefited minoritycybersecurity students?

INITIATOR

Describe any programs, resources, etc. benefiting minority cybersecurity students that you have developed or helped to develop. How specifically have minority cybersecurity studentsbenefited? If applicable, approximately how many minority cybersecurity students have been assisted?

B.Other Qualifications

Describe additional efforts, accomplishments, characteristics, etc. not covered in the sections above that you feel merit this award.

C.Volunteer Efforts

Describe all of your volunteer efforts (i.e. efforts outside of your job) on behalf of minoritycybersecurity students and/or the ICMCP community. (These can overlap with your other responses.)

NomineePersonalInterests

During theICMCP®AwardsGala,theaudienceenjoyshearing aboutthepersonalsideofour nomineesasthey arecalledtothestage.Pleasetellusaboutoneortwoof thefollowing:

1.Your hobbies: bikeriding and traveling

2.Communityinvolvement:VolunteerattheHumaneSociety

3.A secretambition:TobeaStormchaser

4.Whatyou’ddoifyouwon thelotterywith a BIGpayout: Setup a foundation tosavedistressed animalsandtheenvironment

5.If youcouldmeetanyonedeadoralive,who would itbeand why:GeorgeWashington –I’dloveto learn froma trueleader

6.If youcould bea famousperson,who would you be andwhy:

7.Your favoritemovieandwhy:TwoDaysintheValley –thetwistsareoutrageous

8.Yourmentor

9.Something notmanypeopleknowaboutyou: Ican writebackwards

10.Anything elseyou’d liketo share

Pleasedonotincludeanything you would notwanttheaudience to hear attheAwardsCeremony.

NOMINEE/ NOMINATORDECLARATION ANDDETAILS

Bysubmitting thisform, IbelievethattheinformationI haveprovided iscorrecttothebestofmyknowledge. I authorizethereleaseand useof any and allmaterialsfurnishedin thenomination formforthepurposesofevaluationand judging.

I understand thatthenomineebio and photosubmitted onthisnomination form willbedisplayedontheICMCP® websiteand maybeused in publicityrelated to theICMCP®Awards;and thatallotherinformationwillbetreated asconfidential.

(Electronicsubmission of theformistakento meanthatthetermsandconditionsofthisnomination formareaccepted.)NomineeAuthorization:(typename) NominatorAuthorization: (typenameifapplicable) Date:

SUBMISSION QUICKCHECK LIST

1.Did you completethecontactinformationwhereapplicablein thisdocument?

2.Isthename,titleand company/organization nameofthenomineeasyouwould liketoseeitprinted inmaterialsandon thewebsite?

3.Did you includethenominee’sbioin thisdocument?

4.Did you completethenomination questionssection?

5.Did you completea nominee’spersonalInterestsection?

6.Did you fillin thenomineeauthorization,nominatorauthorization(ifapplicable)and date?

7.Did you senda high-resolution photo

NEXTSTEPS

1.Upon submission,an ICMCPteam memberwillconfirmreceiptofcompleted nomination formand photo.

2.An emailwillfollowwith detailsof theagendaof theICMCP®Annual Conference and Awardsand howtoregisterfortheprogram.Nominees,theirteams,and qualified educators they would liketoinviteareeligibletoattendtheentireICMCP®Annual Conference and Awards.(Aqualified educatorcannotworkforavendor thatprovidesinformation securityproductsor services.)

3.Detailswillalsobeprovidedon hotelregistration,ratesand howtobook your room.

Forallquestions,pleasecontact:

Kate Shackford

Director,Development ICMCP® Nominations

International Consortium of Minority Cybersecurity Professionals

31 Ellis Drive|North Haledon, NJ 07508

P:917.913.0016

Websites:

Thankyou forparticipatinginthe ICMCP®North America Awards.Good luck toyou!