Premier's Volunteer Service Award

Nomination Form

Please print the nomination form using the printer friendly option above or select this Adobe Acrobat version and send it in to the address located on the submitting a nomination page.

Award Category

__Individual __Youth Age: __under 18 __19-24 Community Group

______________________________________________________________________

Nominee

For individual and youth category

__Mr. __Mrs. __Miss __Ms __Dr. __Other ____________________________
(please specify)

Name ______________________ ________________________________
First Last

For community group category only

Full name of Organization _____________________________________

Name of contact person _______________________________________

For all nominees

Address ____________________________________________________

City/Town ___________________________ Postal Code_____________

Telephone _________________________ __________________________________
Residence Business

Occupation ___________________________________________________________
(if applicable)

Submitted by

__Mr. __Mrs. __Miss __Ms __Dr. __Other (please specify)

________________________________________________________________________

Name ______________________ Last______________________________

Title and Organization___________________________________________
(if applicable)

Address _____________________________________________________

City/Town ______________________________ Postal Code___________

Telephone _______________________ ____________________________________
Residence Business

Relationship to nominee _______________________________________

References

Name _________________________ _______________________________

Telephone _________________________ ____________________
Residence Business

2. Name ________________________ _________________________

Telephone _________________________ ____________________
Residence Business