Citizen of the Year Nominee

Fill out the form below to nominate a Citizen for the 2021 Awards of Excellence Gala - Citizen of the Year Award.

First Name*

Last Name*

Email Address*

Phone*

Name of Nominee*

Describe the nominee’s outstanding leadership and commitment to the Brockville and district communities.*

Give examples of the nominee’s outstanding citizenship. *

Illustrate the vision and civic pride demonstrated by the nominee.*

How does the nominee positively impact and contribute to the betterment of Brockville and district communities?*

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Nomination Submitted By

Is the nominee aware of this nomination?*

Is nominee a member of the Brockville & District Chamber of Commerce?*

Contact information for nominator*

contact information for nominee*

Additional information