2013 Nomination Form

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Prime Minister's Awards for Teaching Excellence

2013 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.

Last Name __________________________ First Name ___________________________

(Please provide names as they should appear on certificates)

Home Address ______________________________________

City/Community ____________________________ Prov./Terr. ____________ Postal Code _____________

Tel. (H) (____) ________________________ E-mail (H) __________________________________

Tel. (W) (____) _______________________ E-mail (W) __________________________________

Is the nominee a Canadian citizen or permanent resident?

□ Yes □ No

Does the nominee teach a minimum 2.5 days per week?

□ Yes □ No

Is this a team nomination?

□ Yes □ No

Does the nominee self-identify as an Aboriginal teacher?

□ Yes □ No

As of the nomination deadline, does the nominee teach at a First Nation school on-reserve?

□ 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 IC PPU 001. Nominees may access, request correction of, or have a notation attached to the information about them at the address in the section Address. Each award recipient’s name, school, community, and work contact information are included in short biographies published for the media and on the Internet. Award recipients’ photographs may also be used in promotional and information materials by the Prime Minister’s Awards for Teaching Excellence.

Nominator

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

□ Dr. □ Mr. □ Mrs. □ Ms.

Last Name __________________________ First Name ____________________________

Organization Represented (when applicable) ____________________________________________________

Address __________________________________________________________________

City/Community ____________________________ Prov./Terr. ____________ Postal Code _____________

Tel. (H) (____) ________________ Tel. (W) (____) __________________ Fax (____) _________________

E-mail ____________________________________________________________________

Principal/Supervisor

□ Dr. □ Mr. □ Mrs. □ Ms.

Last Name __________________________ First Name ___________________________

Tel. (W) __________________________ Email ___________________________

Nominee's School Information

Full Name and Address of School (or school board if teacher is not affiliated with a particular school).
(Cash awards will be shared with this teaching institution if the nominee is chosen for a Certificate of Excellence.)

School Name _____________________________________________________________

School Address ___________________________________________________________

City/Community ____________________________ Prov./Terr. ____________ Postal Code _____________

School Telephone _______________________________ School Fax _______________________________

School E-mail ____________________________________________________________

School Website ___________________________________________________________

Teacher's Website at school, if different ______________________________________________

Grades currently taught ____________________________________________________

Subject(s) currently taught _________________________________________________________

Does the nominee use information and communications technologies (ICT)
in his or her classroom? □ Aboriginal School? □

Signatures

Nominator

By signing this form, I, the principal/supervisor support this nomination.

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 understand that award-winning ideas and methods will be published in an online exemplary practices publication and I give my release for that purpose. I have also read the Prime Minister's Awards recipient Code of Conduct.

Signature of Nominee _________________________________ Date ________________________

Principal/Supervisor

Signature of Principal/Supervisor ________________________________ Date ________________________

For more information or assistance in completing your nomination,
please call the PMA office at 613-946-0651, or send us an e-mail at pmate-ppmee@gc.ca.

For PMA Office Use Only

Is a copy of the teacher's Certification included?

□ Yes □ No

Is the certificate valid?

□ Yes □ No

Does the nominee have at least three years experience teaching in primary or secondary schools?

□ Yes □ No

Is the nomination text included in the nomination package?

□ Yes □ No

Are the three letters of support included in the nomination package?

□ Yes □ No

Does the nominee meet all criteria to be eligible for a PMA?

□ Yes □ No

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