Accessibility Achievement Award Nomination Form

Please complete the following form to Nominate an Individual, Organization, School or Business for the Tillsonburg Accessibility Achievement Award.

Nominations can be submitted at any time throughout the year.

The Nominee must be one of the following (Please check one) The Nominee must be one of the following (Please check one)

Tillsonburg Resident

Tillsonburg Business

Tillsonburg Organization

Tillsonburg School

Other - Provides programs or services that benefit the residents of Tillsonburg.

Please select the Type of Nomination being submitted.

Business

Individual

Organization

School

Please select the Award Category(s) to which your Nomination applies.

Customer Service

Built Environment

Education

Employment

Recreation

Volunteer

Nominee's Name

Please provide the Name of the Business/Organization/School (if applicable).

Nominee's Phone Number

Cell Phone Number

Nominee's Street Address

Nominee's E-mail

Reason for Nomination (Please briefly describe the achievements of the Nominee)

Please attach any additional supporting material (i.e. testimonials, photographs, media stories, etc.)

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

Nominator's Name

Nominator's Address

Nominator's Phone Number

Cell Phone Number

Nominator's Email Address

Declaration

Personal Information contained on this form is collected pursuant to Section (29) of the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990 and will be used for the purposes of determining the recipient(s) of the Accessibility Achievement Award.

Questions regarding this collection should be directed to the Town Clerk, Town of Tillsonburg, 200 Broadway, Tillsonburg, ON, N4G 5A7; Telephone 519-688-3009 Ext. 3224.

Please check declaration box.

I hereby declare that all of the information provided in this Nomination application is true and correct to the best of my knowledge.

Accessibility Achievement Award Nomination Form

Contact(s)