City of London Diversity, Race Relations and Inclusivity Award - Nomination Form

Note: Fields marked with ★ are mandatory.

Section 1 - Information of Group/Organization Being Nominated

Name of Youth, Group or Organization you are nominating:

Address of Nominee (please include City, as well as postal code)

Name(s) of Contact People (including position titles)

Business Phone #

Business E-mail address

Organization Website (if one exists)

Which of the following categories does this group/organization fit into?

Small business/small labour (49 or fewer employees/members)
Large business/large labour (50 or more employees/members)
Social/community services (including Not-for-Profits) (49 or fewer employees/members)
Social/community services (including Not-For-Profits) (50 or more employees/members)
Youth/young adult groups or organizations (younger than 26 years of age)

Does the nominee meet the eligibility criteria?

Yes
No
Not sure

Section 2 - Your Reason for Nominating

What is the initiative this group/organization implemented?

At what time during this year did this initative take place? (eg. Spring 2017)

Name the key individuals, departments or committees involved:

Brief description of initiative:

How has the initiative contributed to the promotion of diversity, race relations, inclusivity and human rights in London and promoting London as a welcoming city? eg. Number of people who benefited from this initiative, success stories, etc.

What short or long-term impact has/will the initiative have on the promotion of diversity, race relations, inclusivity and human rights in London and promoting London as a welcoming city?

What is the potential for expansion and/or inspiration for replication of the initiative?

How can receiving this Award be used to further promote diversity, race relations, inclusivity and human rights in London and to further promote London as a welcoming city?

Do you wish to attach a document or photo in support of your nomination?

Another document or photo?

Another document or photo?

Another document or photo?

Section 3 - Nominator Information

Your Name

Your Address (please include postal code)

Your Phone #

Submitter E-mail (In case we need to reach you regarding this submission)

By submitting this form, you are hereby confirming that the Nominee has consented to the nomination.

Please be advised that all nominations submitted become part of the public record. The nominations will be published on a public agenda and made available electronically thorugh the City of London public Internet website.

The personal information collected on this application form is collected under the authority of the Municipal Act, 2001, as amended, and will be used to respond to questions or comments submitted to the City of London from members of the public using www.london.ca, City of London Diversity, Race Relations and Inclusivity Award - Nomination Form. Questions about this collection of personal information should be addressed to the City Clerk, 300 Dufferin Avenue, PO Box 5045, London, ON N6A 4L9. Tel: 519-661-CITY (2489) ext. 5590.

Note: If the form does not appear to submit, please open each section and confirm that there are no issues or missing required fields.