Nomination Form
Emerson Douyon Multiculturalism Award Candidate

RTF | PDF

Candidate Infortion

Title: Dr. Mr. Ms. Mrs.

Last Name:

First Name:

Date of Birth: _____/___/___

Gender (√): M___  F___

Canadian Citizen(√): Yes___  No:___

Address:

City:

Province:

Postal Code:

Telephone:

Sponsor Information

Title: Dr. Mr. Ms. Mrs.

Last Name:

First Name:

Justification:

Additional pages attached:(√): Yes___  No:___

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Sponsor’s Signature: ________________________

Date: _____/___/___

Nominee’s Supervisor/
Manager/Warden/Director’s Signature:________________________

Date: _____/___/___

AC/RDC Signature: ________________________

Date: _____/___/___

NOTE: In order to submit a nomination, please contact
Johanne Vernet, National Manager, Ethnocultural Services Section (ESS),
Correctional Service Canada (CSC), toll-free at 1-888-273-3802, or by email