Nomination Form for the Council of Canadians with Disabilities Award

Name of Candidate

_______________________________________________________________________

Address

_______________________________________________________________________

City/Town           Province/Territory        Postal Code

_______________ / ________________________ / ____________________________

Telephone (area code):
residence                office                            fax

__________________ / ________________________ / _________________________

E-mail

_______________________________________________________________________

Nominated by: (Name of the individual and/or organization)

______________________________________________________________________

Address

______________________________________________________________________

City/Town           Province/Territory        Postal Code

________________ / _______________________ / ___________________________

Telephone (area code):
residence                  office                         fax

________________ / _____________________ / ____________________________

E-mail

_____________________________________________________________________

Please enclose the following material:

Guidelines for Letters of Support:

This information should be submitted no later than November 15 of each year.

The Alberta Committee of Citizens with Disabilities
106, 10423 178 Street NW
Edmonton, AB   T5S 1R5
Fax (780) 488-3757
E-mail: accd@accd.net