Creative Retirement Manitoba's Ageless Heroes Nomination Form

1. Nominee

Name of Individual
(please print to ensure correct spelling)

Address

City/Town Postal Code

Telephone (business) Telephone (residence)

Nomination for:      ___ Love of Learning     ___ Bridging the Generations

2. Nominator

Name of Individual
(please print to ensure correct spelling)

Address

City/Town Postal Code

Telephone (business) Telephone (residence)

E-Mail ______________________________________

3. Nominator's Written Statement (To be attached)

4. Letters of Support are attached from:

    1. Name:

    2. Name:

Nomination form and jury discussion will remain confidential.
Deadline for completed nominations is 5:00 pm, Friday, October 8, 2010
Print this form out, complete it, and mail to: Creative Retirement, 270 Sherbrook St, Winnipeg, MB R3C 2B9.

Have you included? Completed Nomination form ___       Nominators written statement ___         Two additional letters of support ___