Senior Islanders of the Year

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Personal information on this form is collected under Sections 31(c) and 32(1)(n) of the Freedom of Information and Protection of Privacy Act as it relates directly to and is necessary for the PEI Senior Islanders of the Year Awards Program, and will be used for the purpose of assessing nominations and contacting potential award winners. If you have any questions about this collection of personal information, you may contact the coordinator of the PEI Senior Islanders of the Year Awards Program, 11 Kent Street, Jones Building, Charlottetown, PE C1A 7N8, tel: (902) 620-3785

Identification

Enter your contact information as the nominator

First Name

Middle Initial

Last Name

Address 1

Address 2

City, Town, or Community

Province

Postal Code

Exemple C1B 0X1 ou 12345

Country

Telephone Number

Exemple 902-555-5555

Email Address