Government of Ontario
Ministry of Citizenship and Immigration

The Ontario Volunteer Service Awards
NOMINATION FORM

Nominators must certify nominations as outlined on the final page of this form.

Personal information on this form is collected under the authority of the Ministry of Citizenship and Culture Act, R.S.O.1990, c.M.18, s.4 and will be used to determine eligibility and notify recipients of the Ontario Volunteer Service Awards. For further information, please contact the Manager, Ontario Honours and Awards Secretariat, 400 University Avenue, 4th Floor, Toronto ON M7A 2R9, Tel.: 416 314–6608 Fax: 416 314–7743.

(Please print clearly and complete in full)

NOMINATING GROUP or ORGANIZATION Name
Address (Street or P.O. Box No.)
Suite/Unit # City/Town Postal Code
County E–mail
Telephone: Fax:
Year group or organization formed

Please indicate below the total of volunteers in group or organization: Senior Citizens (ages 65 years and over) Adults (over 24) Youth (24 and under)

HEAD OF GROUP or ORGANIZATION (CHAIR, PRESIDENT, ETC.) Mr. Mrs. Ms. Other
First Name Last Name
Title
Address (Street or P.O. Box No.)
Suite/Unit # City/Town Postal Code
Telephone: E–mail:

CONTACT Mr. Mrs. Ms. Other
First Name Last Name
Title E–mail:
Telephone: Fax:

Brief description of objectives and activities of your group or organization (max. 50 words)

VOLUNTEER BEING NOMINATED (maximum of seven nominees of which at least one must be a youth)

Mr. Mrs. Ms. Other Other
First Name Last Name
Residential Address (Street or P.O. Box No.)
Apt./Unit # City/Town Postal Code
Telephone:

AGE CATEGORY (please check one only) Senior Citizen (65 years and over) Adult (over 24) Youth (24 and under)
Number of consecutive years as a volunteer in the organization

Details of volunteer service with nominating group or organization, including items of special interest: (max. 50 words)

CEREMONY LOCATION Invite recipient to ceremony closest to their address
Invite recipient to ceremony closest to the organization’s address
Preferred language of communication

VOLUNTEER BEING NOMINATED

Mr. Mrs. Ms. Other Other
First Name Last Name
Residential Address (Street or P.O. Box No.)
Apt./Unit # City/Town Postal Code
Telephone:

AGE CATEGORY (please check one only) Senior Citizen (65 years and over) Adult (over 24) Youth (24 and under)
Number of consecutive years as a volunteer in the organization

Details of volunteer service with nominating group or organization, including items of special interest: (max. 50 words)

CEREMONY LOCATION Invite recipient to ceremony closest to their residential address
Invite recipient to ceremony closest to the organization’s address
Preferred language of communication

VOLUNTEER BEING NOMINATED

Mr. Mrs. Ms. Other Other
First Name Last Name
Residential Address (Street or P.O. Box No.)
Apt./Unit # City/Town Postal Code
Telephone:

AGE CATEGORY (please check one only) Senior Citizen (65 years and over) Adult (over 24) Youth (24 and under)
Number of consecutive years as a volunteer in the organization

Details of volunteer service with nominating group or organization, including items of special interest: (max. 50 words)

CEREMONY LOCATION Invite recipient to ceremony closest to their residential address
Invite recipient to ceremony closest to the organization’s address
Preferred language of communication

VOLUNTEER BEING NOMINATED

Mr. Mrs. Ms. Other Other
First Name Last Name
Residential Address (Street or P.O. Box No.)
Apt./Unit # City/Town Postal Code
Telephone:

AGE CATEGORY (please check one only) Senior Citizen (65 years and over) Adult (over 24) Youth (24 and under)
Number of consecutive years as a volunteer in the organization

Details of volunteer service with nominating group or organization, including items of special interest: (max. 50 words)

CEREMONY LOCATION Invite recipient to ceremony closest to their residential address
Invite recipient to ceremony closest to the organization’s address
Preferred language of communication

VOLUNTEER BEING NOMINATED

Mr. Mrs. Ms. Other Other
First Name Last Name
Residential Address (Street or P.O. Box Number)
Apt./Unit # City/Town Postal Code
Telephone:

AGE CATEGORY (please check one only) Senior Citizen (65 years and over) Adult (over 24) Youth (24 and under)
Number of consecutive years as a volunteer in the organization

Details of volunteer service with nominating group or organization, including items of special interest: (max. 50 words)

CEREMONY LOCATION Invite recipient to ceremony closest to their residential address
Invite recipient to ceremony closest to the organization’s address
Preferred language of communication

VOLUNTEER BEING NOMINATED

Mr. Mrs. Ms. Other Other
First Name Last Name
Residential Address (Street or P.O. Box Number)
Apt./Unit # City/Town Postal Code
Telephone:

AGE CATEGORY (please check one only) Senior Citizen (65 years and over) Adult (over 24) Youth (24 and under)
Number of consecutive years as a volunteer in the organization

Details of volunteer service with nominating group or organization, including items of special interest: (max. 50 words)

CEREMONY LOCATION Invite recipient to ceremony closest to their residential address
Invite recipient to ceremony closest to the organization’s address
Preferred language of communication

VOLUNTEER BEING NOMINATED – MUST BE A YOUTH

Mr. Mrs. Ms. Other Other
First Name Last Name
Residential Address (Street or P.O. Box Number)
Apt./Unit # City/Town Postal Code
Telephone:

AGE CATEGORY (Nominee must be a youth) Youth (24 and under) Number of consecutive years as a volunteer in the organization

Details of volunteer service with nominating group or organization, including items of special interest: (max. 50 words)

CEREMONY LOCATION Invite recipient to ceremony closest to their residential address
Invite recipient to ceremony closest to the organization’s address
Preferred language of communication

CERTIFICATION CLAUSE

Information for Nominators Before signing the certification below, please ensure that you have read the accompanying information sheet entitled the Ontario Volunteer Service Awards and are satisfied the nominations you have made fit within the parameters of the award program as described and all of the nominees are, in your opinion, deserving of the award.

Nomination Certification I hereby certify that I have been a member in good standing in the above–named group or organization. To the best of my knowledge I certify that all of the information provided on this form is true, and assert it is my belief that each of the nominees listed above is deserving of an Ontario Volunteer Service Award since he/she meets the requirements of the award.

Name (print) Title
Signature Date

If you require additional nomination forms, please photocopy the original. Only original signatures are accepted by mail. Completed forms must be received by January 25.

SEND TO:
Ontario Honours and Awards Secretariat
Ontario Ministry of Citizenship and Immigration
400 University Avenue, 4th Floor
Toronto ON M7A 2R9

61–544 (11/2007) © Queen’s Printer for Ontario, 2007