Queen Elizabeth II Diamond Jubilee Medal Nomination Form

Nominee Information

Last Name Give Name(s) Street Address Apartment/Unit# City/Town Province Postal Code Phone Email Address Gender Male
Female
Language English
French
Date of Birth (mm/dd/yy) Honorary Title None Chief Your Excellency Your Excellency The Right Honorable Your Honour Your Honour The Honourable Your Worship The Honourable The Right Honourable
Other Title Military? No
Yes Rank(Specify) Is the Nominee a Canadian citizen? Yes
No
Is the Nominee currently alive? Yes
No
Post-nominals (Optional) Current Position of Nominee (Optional) Field of Endeavour Aerospace
Business/Commerce
Communications
Engineering
Heritage & History
Philanthropy
Public Service
Social Services
Veteran
Architecture
Industry/Economics
Community Service
Environment
Humanitarian Aid
Politics
RCMP
Sports
Voluntary Service
Arts & Culture
Canadian Forces
Education
Health Care
Multicultural
Protective Services
Religious Science
Technology
Other Field of Endeavour

Summary

Use this space to provide a short citation or brief summary of the nominee's achievements (up to 250 characters or 40 words)

Nominator Information

Last Name Given Name Street Address Apartment/Unit # City/Town Province Postal Code Phone E-mail Address Relation to the Nominee How long have you known the Nominee?

References (optional)

List up to three other references willing to vouch for your Nominee. Reference 1 : Full Name Reference 1 : Relation to Nominee Reference 1 : Company/Organization Reference 1 : Phone Reference 1 : Address

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Reference 2 : Full Name Reference 2 : Relation to Nominee Reference 2 : Company/Organization Reference 2 : Phone Reference 2 : Address

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Reference 3 : Full Name Reference 3 : Relation to Nominee Reference 3 : Company/Organization Reference 3 : Phone Reference 3 : Address

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May we contact your listed references? Yes
No
May we contact you for more information? Yes
No

Certification

I certify that the answers enclosed are true and complete to the best of my knowledge Yes
No
Date