Nomination Form for: Prairie/NWT Heart Award - 2019

Purpose: The Prairie/NWT Region wishes to recognize the outstanding contributions of a PIPSC member active in an executive or active in committee work.

Eligibility: All regular or retired Prairie/NWT PIPSC members in good standing.

Nominee: First and last name:

Executive/Committee position(s) held:

Contact Information:

Reason(s) for Nomination:

(Please give specific examples of how they meet the selection criteria.)

(Please use additional space as required)

Signatories:

A minimum of two members of two different constituent bodies (region, branches and or committee member is required for the nomination to be valid).

Nominator’s name:

Representing (name of constituent body/committee)

Nominator’s name:

Representing (name of constituent body/committee)

Deadline: The nomination deadline is Friday, April 26, 2019.

Please return the nomination form to Prashila Chand at pchand@pipsc.ca or by fax to 780.426.5962 or 1.800.856.4963