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Third
Young Leaders in Rural Canada Awards

NOMINATION FORM

This form was for the third Awards. The nomination period closed on January 30, 2006. We would like to thank all those who submitted a nomination package.


Please fill-out the nomination form created in Word, WordPerfect or .PDF (Acrobat) format.


(A) AWARD CATEGORY

(A1) Young rural Canadians can only be nominated or self-nominate in one category of the Awards. (Place an "X" in the appropriate box.)

INNOVATION   LEADERSHIP   PARTNERSHIP  

(A2) This submission is a: nomination    
self-nomination   (Go to section (B).)

 

(A3) The nominee is aware of his/her nomination: Yes   No  

 

 

(B) ELIGIBILITY

All fields must be completed. [Refer to the Call for Nominations document to determine eligibility.]

The nominee or self-nominee: Yes No
(B1) was between 18 and 29 years old in 2004 or 2005    
(B2) undertook an initiative in 2004 or 2005* which demonstrated a commitment and contribution to the wellness of rural, remote and/or northern Canada.

*Specify which year(s) here:

    
(B3)
is currently living in a "rural" community* OR is from a "rural community*
* Community: * Community:
Prov./Terr.: Prov./Terr.:

 

 

(C) NOMINEE / SELF-NOMINEE INFORMATION

All fields must be completed. [If you are self-nominating, go to section (E) after completing section (C).]

Name
(Mr./Mrs./Ms.)		  
Language of preference English     French    
Gender Male   Female  
Age AND date of birth Current
age		   mm/dd/yy  
Complete mailing address




  
Tel. numbers
(Include area code)		 Day   Specify:
(work,
home,
cellular)		  
Evening   Specify:
(home,
cellular)		  
Fax number  
E-mail  
                 

 

 

(D) NOMINATED BY

Name
(Mr./Mrs./Ms.)		  
Title  
Organization
 		   
Complete mailing address



  
Tel. numbers
(Include area code)		 Day   Evening  
Fax number  
E-mail  

 

 

(E) ENDORSEMENTS
[Must be completed for a self-nomination ONLY.]

Provide the names and coordinates of two people and one group or organization.

ENDORSER #1
Name of person
(Mr./Mrs./Ms.)		  
Title / Organization
 		  
Complete mailing address




  
Tel. numbers
(Include area code)		 Day   Evening  
Fax number  
E-mail  
ENDORSER #2
Name of person
(Mr./Mrs./Ms.)		  
Title / Organization
 		  
Complete mailing address




  
Tel. numbers
(Include area code)		 Day   Evening  
Fax number  
E-mail  
ENDORSER #3
Name of group / organization   
Contact person
(Mr./Mrs.Ms.)		  
Complete mailing address




  
Tel. numbers
(Include area code)		 Day   Evening  
Fax number  
E-mail  

 

 

(F) SUBMIT YOUR NOMINATION PACKAGE

The submission package must include:

  1. the completed nomination form. [Self-nominees must obtain the endorsements of two people AND one group or organization. If this requirement is not met, the submission will be screened out.]
  2. the 1-2 page rationale or summary (on letter size paper only) that justifies the nomination or self-nomination and fully supports how the individual meets the basic and category-specific criteria. [Refer to the Call for Nominations document for details on preparing the rationale/summary.]

The following is optional:

  • A submission may include supporting documents (e.g. letters of support, products, news articles, etc) not exceeding four pages on letter or legal size paper only. 

Nominators and self-nominees can send their submission package to the following person:

Ms. Sylvie Chartrand
Rural Secretariat
Agriculture and Agri-Food Canada
1341 Baseline Road
Tower 7, 6th Floor, Skyline Building
Ottawa, Ontario K1A 0C5
Tel. (toll free): 1 888-781-2222
Fax (toll free): 1 800 884-9899
E-mail: chartrs@agr.gc.ca

When sending the submission package by:

  • e-mail or fax, it must be received no later than Monday, January 30, 2006.
  • mail, it must have a post-mark date of January 30, 2006 or sooner.

 

Note:  

Submissions received after the above noted date will not be considered. All submissions become the property of the Rural Secretariat. Materials submitted will not be returned. Information from the rationale/summary and supporting documents may be used in communication products or for promotional purposes.

The information is required by the Rural Secretariat, Agriculture and Agri-Food Canada, to contact nominees/self-nominees for the third Young Leaders in Rural Canada Awards, including their nominators and endorsers. The information will be protected under the provisions of the Privacy Act. Some information may be accessible or protected as required under the provisions of the Access to Information Act.

Date Modified: 2006-01-31