Required fields are marked with asterisks (*)

Accessibility Award Nomination Form

The Accessibility Award is presented annually to promote accessibility and celebrate those in the community that have contributed to a barrier free Leamington.

Is the nominee(s) aware of the nomination?

Yes

Nominee Information

Name of Nominee/Group (if applicable)

Name of Group Representative (if applicable)

Mailing Address

Town/City

Province

Postal Code

Phone Number

E-mail Address

Nominator Information

Name

Mailing Address

Town/City

Province

Postal Code

Phone Number

E-mail Address

What is your relationship/affiliation with the nominee(s)?

How does this individual, business or community organization/group, through their inclusive advocacy or practices, promote accessibility and contribute to a barrier free Leamington?

Include up to two (2) testimonials supporting how the Nominee has worked with others to promote accessibility in the community (ex. volunteer experience, photos, newspaper clippings, etc).

Include any supporting documentation for this nomination.

Browse…

Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Signature of Nominator

Clear

Privacy Statement:

The information requested is collected and used to determine eligibility and selection of Accessibility Award recipients. Excerpts may be presented during the award ceremony and subsequent publications and display. A list of award recipients will also be publicized. The information will be collected, used and disclosed in accordance with the Municipal Freedom of Information and Protection of Privacy Act. Questions about the collection and use of this information may be directed to the Manager of Legislative Services/Clerk, Municipality of Leamington, 111 Erie Street North, Leamington, Ontario, N8H 2Z9, Telephone: 519-326-5761.

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