Appendix “A”
National Ethnic Press and Media Council of Canada
RECOGNITION AWARDS
NOMINATION FORM
CATEGORY: (specify)
□ INDIVIDUAL /
□ ORGANIZATION
NOMINEE:
Nominated for the _______ Award
Last Name (Ms./Mr.): ___________
Other Names:______________
Date of Birth
(If Youth): . . . ../ . . ./ . . . . . .
|
If Organization, Name: ____________________ Address: __________ Apt. #______ City: ____________ Postal Code:___________ Telephone: Home # (__ __ __) __ __ __ - __ __ ____ Work # (__ __ __) __ __ __ - __ __ __ __ NOMINATED BY: Name (Ms./Mr. First/Last): __________________________________ Organization Represented (If any): _________________________ If Nominated by Organization, Contact Person: _______________________ Address: ___________________ Apt. #________ City: _____________________ Province: _________ Postal Code: ____________ Telephone: Home # (__ __ __) __ __ __ - __ __ __ __ Work # (__ __ __) __ __ __ - __ __ __ __ |
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NOMINEE'S CONSENT TO NOMINATION:
I
am aware of my nomination made by the above-mentioned Person/Organization
for the
Award
to be presented by the
National
Ethnic Press and Media Council of Canada
Should
I become an Award recipient, I agree to be present at the Awards Ceremony
and
to be publicly acknowledged for publicity purposes before and after the
Awards.
_____________________
Signature of Nominee
Signature of Nominating Individual (or Organization Representative)
Position:__________________________
BRIEF SYNOPSIS
NOMINEE’S
CONTRIBUTION/S TO THE COMMUNITY AND/OR ACHIEVEMENTS:
OTHER
SIGNIFICANT CONTRIBUTION/S AND ACHIEVEMENT/S:
ANY
OTHER RELEVANT BACKGROUND DETAILS:
PAST
AND PRESENT MEMBERSHIP OF COMMUNITY ORGANIZATIONS, ETC:
PERSONS
WHO MAY BE CONTACTED FOR FURTHER INFORMATION ABOUT THE NOMINEE:
1.
Name:
..................................................................................…
Position: ..................................................................................
Address:
..................................................................................
...................................................................................................
................................................................
Postcode: . . . . . . .
Telephone:
.............................................................................
2.
Name:
..................................................................................…
Position:
..................................................................................
Address:
..................................................................................
...................................................................................................
................................................................
Postcode: . . . . . . .
Telephone:
.............................................................................
AS
INDICATED EARLIER PLEASE INCLUDE ON SEPARATE SHEETS OF PAPER:
·
A
summary (maximum 500 words) for nominating this individual or
organization, stating experience, service, contribution and achievements.
