Prescott and Russell jp st. Pierre Award

* Mr.             Mrs.            Ms.            D^r.            Other   

* First Name:

* Last Name:

* Home address:

* City :

* Postal Code :

* Home Telephone Number: (e.g., 613-555-5555)

Other Telephone Number: (e.g., 613-555-5555)

E-mail Address:

Organization (if applicable):

Nominator Information (your name)

* Mr.              Mrs.             Ms.           D^r.            Other    

*First Name :

* Last Name:

* Relationship to Nominee:

* Street Number:

* Street Name:

Unit/Apt/Suite:

* City:

* Postal Code:

* Home Telephone Number: (p. ex., 613-555-5555)

Other Telephone Number: (p. ex., 613-555-5555)

* E-mail Address:

Summary of Nominee’s Achievements 

Each nomination form MUST include a short summary of the nominee’s contribution or accomplishments.

* 1) Overview of why you are nominating the candidate (max.250 words)

2) Written testimonials from at least two individuals (including contact information), other than the nominator, who have first-hand knowledge of the nominee’s accomplishments (max.350 words)

Testimonial # 1

* Mr.             Mrs.            Ms.           Dr.          Other     

*First Name:

* Last Name :

* Home Telephone Number: (p. ex., 613-555-5555)

Other Telephone Number: (p. ex., 613-555-5555)

E-mail Address:

*Please ensure that you include sufficient information to give the Selection Committee a clear idea of the nominee’s character and the impact of his/her contribution..

Testimonial # 2

* Mr.             Mrs.            Ms.           Dr.          Other     

*First Name:

* Last Name:

* Home Telephone Number: (p. ex., 613-555-5555)

Other Telephone Number: (p. ex., 613-555-5555)

E-mail Address:

*Please ensure that you include sufficient information to give the Selection Committee a clear idea of the nominee’s character and the impact of his/her contribution..

3) Additional material in support to this nomination (i.e. testimonial letters, media stories, tribute, etc.) that provides new information and insight into the nature of the nominee’s accomplishments can be sent by