Diamond Jubilee Medal Nomination Form.pdf

The Queen Elizabeth II Diamond Jubilee MedalAn Invitation to Nominate CandidatesPlease complete this nomination form and forward it to the Jubilee Medal NominationsCommittee c/o Tricia Diduch, Communications ConsultantFax: (613) 563-4998E-mail: triciad@cdnaids.ca.Full Name of the Nominee:Rank or Title:Address:Telephone Number:E-mail Address:1. To your knowledge, how long has the candidate been involved in the HIV/AIDS movement?5-10 years 11 – 15 years 16 – 20 years 21 or more years2. In the space provided below:a. describe the nominee’s LOCAL leadership achievements (e.g. one city or one ASO) (if applicable)b. describe the nominee’s REGIONAL leadership achievements (e.g. regional networks, provincialcontributions, etc.) (if applicable)c. describe the nominee’s NATIONAL leadership achievement s (e.g. pan-provincial, National ASO’s) (ifapplicable)3. Describe the nominee’s innovative achievements (for example: developed/designed new programs or services,developed best or innovative practices, founded new programs, research, etc.).

4. Describe the nominee’s achievements in supporting the well-being of people living with and affected byHIV/AIDS in Canada.5. Describe the nominee’s achievements in supporting or reflecting the GIPA (Greater Involvement ofPeople Living with HIV/AIDS) principle either personally or professionally.6. Describe the nominee’s achievements in policy and /or governance (for example: membership ongovernance committees, participation/advocacy re: policy development, etc.).Signature: __________________________________________________________ Date: ____________________Phone number:E-mail:2