Nomination Form 

Emerson Douyon Multiculturalism Award Candidate

Nominee Information 	
Last Name :		First Name:		
Work address:		Province:		
City:		Postal Code:		
Position - Division:		Telephone :		
E-mail:		Cellular:		

Status:	CSC employee:		Within an institution: 		Member of the public:
		
	Volunteer :		Within the community:		Other (specify):		

Sponsor Information 	
Last Name :		First Name:		
Work address:		Province:		
City:		Postal Code:		
Position – Division:		Telephone:		
E-mail:		Cellular:		

Status:	Employee Supervisor or Manager:		Colleague :		Member of the public :		
	Volunteer supervisor:		Friend :		Other (specify):		

Justification
Additional pages attached:	Yes :		No :		
1.	The candidate promotes initiatives that support CSC’s multiculturalism objectives.

	
2.	The candidate demonstrates support to the reintegration of ethnocultural offenders. 

	
3.	The candidate facilitates initiatives such as mentorship, volunteerism, leadership, and civic education among ethnocultural offenders.

	

4.	The candidate promotes inter-cultural understanding and Canadian values (democracy, freedom, human rights and rule of law) within CSC, through institutional or community initiatives, with the objectives of addressing issues of cultural social exclusion and radicalization.

	
5.	The nomination package demonstrates that the candidate has had a positive impact on the workplace and/or within their community.

	

Approval 
Sponsor’s Signature :	Name in script letters:

	Signature :
	Date :	
Candidate’s Manager Signature :	Name in script letters :

	Signature :
	Date :	
Candidate’s Director Signature:	Name in script letters :

	Signature :
	Date :	
Assistant Commissioner/Regional Deputy Commissioner Signature (or representative) : 	Name in script letters:

	Signature :
	Date :