Return with supporting information by e-mail, fax or mail to: World University Service of Canada c/o Carol Dolbel cdolbe
THE LEWIS PERINBAM AWARD IN INTERNATIONAL DEVELOPMENT NOMINATION FORM GUIDELINES AND INSTRUCTIONS. PLEASE READ CAREFULLY. ABOUT THE LEWIS PERINBAM AWARD The award recognizes significant volunteer efforts that: • improve people’s lives in the developing world; • engage and inspire Canadians to undertake volunteer action; • offer new ways of thinking about and/or addressing development challenges.
EACH NOMINEE MUST: A. be a Canadian citizen; and B. have made a significant volunteer contribution to international development. The award commends individuals who make a noteworthy volunteer contribution to international development, rather than paid professionals in this arena. However, paid professionals who make a significant voluntary effort are also eligible for the Lewis Perinbam Award.
REQUIRED INFORMATION The nominator must provide a long description (maximum 1000 words) of this nominee’s accomplishments in the field of international development. This description must include: • Background on the organization with which the nominee is associated (if applicable). • Details of the specific contribution(s) of the nominee, including, amongst other possible issues, the extent to which the nominee’s work improves people’s lives in the developing world; engages and inspires Canadians and others to undertake volunteer action; identifies new ways of thinking and/ or addressing difficult development challenges; demonstrates tangible, quantifiable and sustainable outcomes; and reflects an initiative that can be replicated, followed or built upon by others.
SUPPLEMENTARY INFORMATION To assist the Trustees of the Lewis Perinbam Award further in choosing a candidate, a letter(s) of recommendation/support and/or an article(s), clearly documented as to source and date, are most welcome, and can serve to strengthen greatly this nomination. A maximum of 10 pages of this supplementary information should be submitted. Please save your completed form using the following naming: First Name_Last Name_Lewis_Perinbam_Nomination Return with supporting information by e-mail, fax or mail to: World University Service of Canada c/o Carol Dolbel
[email protected] | Fax: 1.613.798.0990 | 1404 Scott St., Ottawa, ON, K1Y 4M8, Canada
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NOMINEE’S PERSONAL INFORMATION Name Home Address City
Apt Province
Postal Code
Telephone
Fax
E-mail
BUSINESS INFORMATION (IF APPLICABLE) Company Name
Title
Business address City
Apt Province
Postal Code
Telephone
Fax
E-mail
FORMAL EDUCATION Degree, Diploma, Certification
Conferring Institution
Degree, Diploma, Certification
Conferring Institution
Degree, Diploma, Certification
Conferring Institution
PROFESSIONAL CERTIFICATIONS Designation
Organization
Designation
Organization
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OTHER FORMAL RECOGNITIONS (E.G., ORDER OF CANADA)
BRIEF STATEMENT TO THE TRUSTEES AS TO WHY THIS CANDIDATE IS BEING NOMINATED (100 WORDS OR LESS)
Is this individual aware of this nomination?
Yes
No
NOMINATOR’S PERSONAL INFORMATION Name
Title
Organization Telephone
E-mail
Statement indicating who you are and your relationship to the Nominee (100 words)
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