Form Builder - City of Burlington

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Burlington Civic Recognition

By completing and submitting this form, you are nominating someone you feel meets the criteria for civic recognition. Please read the nomination information carefully before completing and submitting your nomination. The selected nominees will be invited to attend a Special Meeting of Burlington City Council to receive their recognition.

Nominator's Information:

First Name:

Last Name:

Address:

City:

Province:

Postal Code:

Nominator's Email:

Are you nominating an individual or an organization/group?

Individual

Group

Nominee's Information:

Address:

City:

Province:

Postal Code:

Nominee's Email

Reason for Nomination:

The information you provide will be used to evaluate and select recipients and may form part of the remarks during the ceremony.

Please ensure that the volunteer examples include all of the below information: (Be sure to correctly spell the names of organizations, achievements and titles).

Number of years nominee has been involved in the activity(ies)
Specific dates nominee worked on project(s)
A brief outline of the nominee’s responsibilities in each of the volunteer roles outlined
How has the nominee's volunteer work impacted the community

What is the reason for the recognition? (please select all that apply)

Contributed significantly to the quality of life in the community through their volunteer efforts

Identified and addressed a priority need in the community and put a solution into action

Achieved Provincial, National or International recognition and, in doing so, have brought honour to the City of Burlington

Description of achievement, community service activities or recognition. See information listed above to fill in response.

Minimum characters: 1

Please add any additional information or documentation you would like to share with the selection committee.

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I have read and understand the eligibility criteria for nominations and confirm that the individual/group nominated in this application meet the criteria.

Yes

Notice of Collection

Personal information contained on this form is collected under the authority of the Municipal Act, 2001, S.O. 2001, c. 25 and will be used to determine the suitability and/or eligibility of individuals for civic recognition. Questions about this collection should be directed to the Committee Clerks, 426 Brant St., P.O. Box 5013, Burlington, Ontario, L7R 3Z6 T: 905-335-7777 ext. 7481.