Step 1 of 5Your Information

Your Information

Tell us who you are. Your details are held in confidence and are used only by the Chancellery to process this nomination.

Name

Your First Name

Your Last Name

Provide an email address or a complete mailing address in the next section.

Your Email Address

We send a single acknowledgement only. The Chancellery does not provide updates on individual nominations.

Confirm Your Email Address

Re-enter your email address to make sure we can contact you.

If you provide an email address, the mailing address is optional.

Address Line 1

Address Line 2 (Optional)

City / Town

State / Province (Optional)

Postal Code (Optional)

Country

Describe Your Relationship

For example: colleague, neighbour, member of the same community, or a member of the public aware of their work.