2024 Prescott and Russell JP St. Pierre Award Nomination Form

Nomination Form
The Prescott and Russell JP St. Pierre Award is bestowed upon deserving residents of the United Counties of Prescott and Russell (UCPR).

This high municipal distinction aims to celebrate the exceptional contributions of individuals in many areas of life within the UCPR, including arts and culture, business and professions, charitable work, health, education, public service, media and communications, sports and recreation, agriculture, the environment, or other areas contributing to the well-being of the UCPR’s residents.

A maximum of 2 awards will be presented on an annual basis during the UCPR Warden’s Banquet.

2. Nominator's Information
Nominator's Title:*

Mr.Mrs.Ms.Dr.Mx.Other
Nominator's Name:*

First NameLast Name
Relationship to Nominee:*
Note: Nominations by immediate family members, self-nominations, and posthumous nominations will not be accepted.
Nominator's Home Address:*

Number and Street Name

Number and Street Name (Cont'd)

CityProvince

Postal Code
Nominator's Home Telephone Number:*
(e.g., 613-555-5555)
Nominator's Other Telephone Number:
(e.g., 613-555-5555, ext. 0000)
Nominator's Email Address:*
example@example.com

3. Summary of Nominee’s Achievements
Each nomination form MUST include a short summary of the Nominee’s contribution or accomplishments.
Overview of why you are nominating the candidate:*

Maximum of 250 words0/250

4. Testimonial of Appraisal
A written testimonial must be submitted from at least one additional individual, other than the Nominator, who has first-hand knowledge of the Nominee’s accomplishments.
Title:*

Mr.Mrs.Ms.Dr.Mx.Other
Name:*

First NameLast Name
Home Telephone Number: *
(e.g., 613-555-5555)
Other Telephone Number:
(e.g., 613-555-5555 ext. 0000)
Email Address:*
exemple@exemple.com
Please ensure that you include sufficient information to give the Selection Committee a clear idea of the Nominee’s character and the impact of their contribution.*

Maximum of 350 words 0/350

5. Additional Material
Additional documents in support of this nomination (e.g., testimonial letters, media stories, tributes, etc.), that provide information and insight into the nature of the Nominee’s accomplishments, can be submitted directly by uploading it through this application.

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