Patrons Nomination Form


PART A:

PLEASE NOTE: Use of the nomination from is mandatory. Nominations received in a nonstandard format will be returned for re-submission. Nomination deadline is June 1st annually.



NOMINATE (Individual, Business, Organization):
___________________________________________

CONTACT NAME:___________________________________________

ADDRESS: (please include postal code)
___________________________________________
___________________________________________
___________________________________________

EMAIL ADDRESS: _______________________________

TELEPHONE: (Home)_____________________ (Business)_____________________

DATE OF BIRTH: __________________________________________

PLACE OF BIRTH: __________________________________________

IF DECEASED PLEASE INDICATE YEAR OF DEATH: _____________________

NEXT OF KIN: (relationship) __________________________________________

ADDRESS: (please include postal code)
__________________________________________
__________________________________________
__________________________________________

TELEPHONE (Home)_____________________ (Business)_____________________

NOMINATOR: __________________________________________

ADDRESS: (please include postal code)
__________________________________________
__________________________________________
__________________________________________

EMAIL ADDRESS: _______________________________

TELEPHONE: (Home)_____________________ (Business)_____________________

_______________________________________                 _______________________________________
(Date of Nomination)
(Signature of Nominator)

PART B:

PARTICIPATION AS A PATRON


PLEASE LIST DETAILS OF SUPPORT PROVIEDED TO SPORT IN REGINA BY THE INDIVIDUAL, BUSINESS OR ORGANIZATION. IF MORE SPACE IS REQUIRED PLEASE ATTACH ADDITIONAL PAGES.









Nominations shall reflect upon the character and conduct of the person or persons nominated. This information should be supported by letters of reference from exemplary individuals from the organization and/or community.


Submit to:
Induction Selection Committee
Regina Sports Hall of Fame and Museum
P.O. Box 3763
Regina, SK
S4P 3N8