Government of New Brunswick

1. Name of person/organization nominating the candidate for the award:
 

 

   

 

   

 

   

2. Name of nominee:
 

 

   

 

   

 

   

* 3. Please describe the ways the nominee has been involved with services for persons with a disability. You may include particular activities, duration and lasting impact.
 

 

   

* 4. Why do you feel this nominee is a deserving candidate for this award:
 

 

   

* 5. Any other information you would like to include:
 

 

   

* If you require more space to answer questions, please attach a separate document with the required information.