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Citizen of the Year Award - Nomination Form

Last Name

First Name

Telephone Number

E-mail Address

I wish to nominate:

Last Name

First Name

Telephone Number

E-mail Address

Please list contributions and achievements in the Town of Prescott. (Please provide specific examples and details).

Personal information on this form is collected under the authority of Section 11 of the Municipal Act, 2001 and will be used by the Town of Prescott to determine the applicant's eligibility for recognition.

Declaration (Please read carefully)

Information provided in this application for recognition is treated confidentially. Review all the information you have provided since it will be used to determine the applicant’s eligibility for recognition. Date and sign the declaration below.

I certify that the statements made by me are true and complete to the best of my knowledge. I understand that any misrepresentation made by me in connection with this application will be sufficient cause for rejection of this application. I authorize investigation of all statements contained in this application, and release from liability any person or company furnishing such information.

Signature of Nominator

Clear

Date