NATIONAL ETHNIC PRESS AND MEDIA COUNCIL OF CANADA
Conseil national de la presse et des medias ethniques du Canada 
                                            Canada’s Other Voices 
Awards Nomination Form

Part A

Details of Nominator

Name of Nominator………………………………..

Community……………………………………………………

Address………………………………………………

City……………….  Province………………. Postal Code…………………

Phone……………….. Fax……………… Email……………………….

Member of NEPMCC since ……………………………..

Part B

Details of Nominee

Name of Nominee……………………………………

Community ……………………..…………….

Category for which recommended……………………………….

Address………………………………………………………………

City…………………………Province……………………Postal Code…………………

Phone………..  Fax………………… Email…………………………..

State in five lines why you are recommending the person (documentary proof may be attached)…………………………………………………………………………

……………………………………………………………………………………..

………………………………………………………………………………………..

…………………………………………………………………………………………….

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………..……………………………………..

Give three specific examples of above statement:

a………………………………………………………………………………
…………………………………………………………………………………..
b…………………………………………………………………………………..
…………………………………………………………………………………….
c………………………………………………………………………………………..
…………………………………………………………………………………………

How is his work relevant for the award (mention in 3 lines)……………………………….

……………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………..

Names and contact details of three other independent persons to whom the reference can be made)

1……………………………………………………………………………………….
…………………………………………………………………………………………..
2…………………………………………………………………………………………
…………………………………………………………………………………………..
3…………………………………………………………………………………………..
………………………………………………………………………………………………

Part C

I ……… (name of Nominator)……………………………… do hereby affirm that the facts stated above are correct and also that I have no personal relationship with the nominee.  

I also declare that I am member of the Council in good standing.  

I also confirm that the nominee has not been convicted of any offence by any court of law.

I understand that that in the event of any fact being found wrong, the award, even if given, shall be withdrawn.

Signatures of the Nominator

Place…………………………………. Date ………………………………………

Part  D

I ………( Name of Nominee)…………………………do hereby affirm that I shall, if accepted, accept the award and shall be present personally at the award ceremony.

 I also confirm that I have no relationship with the nominator. 

I also confirm that I have not been convicted of any offence by any court of law and no criminal case is pending against me in any court. 

I understand that that in the event of any fact being found wrong, the award, even if given, shall be withdrawn. 

Signatures of the Nominee

Place……………………….  Date ………………………….

Note:

1.	Incomplete form in any way shall be rejected without any further reference. Each item must be filled in.
2.	Submission of nomination does not mean acceptance by the award committee or automatic award. 
3.	The decision of the Award committee is final and binding and no communication shall be entertained.
4.	the complete form with necessary documents must be submitted to the Chair of the Award committee before the final date.