Prime Minister’s Awards for Excellence in Early Childhood Education
2009 Nomination Form
Please type or write in BLOCK letters. Please provide a separate form for each nominee.

Nominee’s Personal Information
_______________________________________________________________________________________

Dr. Mr. Mrs. Ms.

First Name _____________________________________ Last Name ________________________________
(Please provide names as they should appear on certificates.)

Home Address ___________________________________________________________________________

City ________________________________ Prov./Terr. ________________ Postal Code ________________

Tel. (H) ( ____ ) ______________________ E-mail (H) ___________________________________________

Tel. (W) ( ____ ) ______________________ E-mail (W) ___________________________________________

For the purposes of the awards designated for Aboriginal early childhood educators, do you self-identify as Aboriginal? Yes No

Personal Information
All personal information collected in nominations is protected under the Privacy Act. It is used by Industry Canada to process the nominations and for related statistical studies. Participation is voluntary. Information will be stored in Personal Information Bank IST-P-PU-015. Nominees may access, request correction of, or have a notation attached to the information about them at the address on page 10. IST/IST-205-05074.

Each award recipient’s name, early childhood setting, community and work contact information are included in short biographies published for the media and at www.pma.gc.ca. Award recipients’ photographs may also be used in promotional and information materials by the Prime Minister’s Awards for Excellence in Early Childhood Education.

Nominator
_______________________________________________________________________________________

To be completed by either an individual nominator or a representative of a nominating group.

Dr. Mr. Mrs. Ms.

First Name _______________________________________ Last Name _____________________________

Organization Represented (when applicable) ______________________________________________________

Address ________________________________________________________________________________

City ______________________ Prov./Terr. __________________________ Postal Code ________________

Tel. (H) (____) _____________________________ Tel. (W) (____) ________________________________

E-mail (H) _________________________________ E-mail (W) _____________________________________

Supervisor (if applicable)
_______________________________________________________________________________________

Dr. Mr. Mrs. Ms.

First Name ________________________________________ Last Name _____________________________

Nominee’s ECE Setting Information
____________________________________________________________________________

Name of setting _______________________________________________________________________

Address ________________________________________________________________________________

City ___________________________________ Prov./Terr. ______________ Postal Code _______________

Telephone ____________________________________ Fax _______________________________________

E-mail address (when applicable)______________________________________________________________

Website __________________________________________________________________________________

Type of setting (e.g. child care centre, Aboriginal Head Start program, family child care program)

_______________________________________________________________________________________

Ages of children in nominee's care ____________________________________________________________

Signatures
_______________________________________________________________________________________

Nominator

Signature of Nominator ___________________________________________ Date _____________________

Nominee

I, the nominee, affirm that all information contained in this nomination package is, to the best of my knowledge, complete and correct. By signing this form, I authorize the Prime Minister’s Awards office to conduct a verification of the information provided in this nomination. I also understand that award-winning ideas and teaching methods will be published in an annual report of exemplary practices and I give my release for that purpose.

Signature of Nominee ____________________________________________ Date _____________________

Supervisor (when applicable)

Signature of Principal/Supervisor ___________________________________ Date ______________________

For more information or assistance in completing your nomination,

call our offices at (613) 946-0651, or send us an e-mail at pmaece-ppmepe@gc.ca

FOR PMA OFFICE USE ONLY
Is the nominee a Canadian citizen?	Yes	No
Is evidence of the nominee’s training in early childhood education and care included in the nomination package?	Yes	No
Is evidence that the early childhood setting in which the nominee works is licensed included in the nomination package?	Yes	No
Does the nominee have at least three years experience in a licensed early childhood setting?	Yes	No
Is the nomination text included in the nomination package?	Yes	No
Are there three letters of support included in the nomination package?	Yes	No
Does the nominee meet all the criteria to be eligible for a PMA?	Yes	No