Province of Manitoba | Premier's Volunteer Service Award

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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