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Please fill in the following form, print it and submit it to the address below. I would like to nominate the following for:
Nominee's Name :
Nominee's Organization /Agency, if applicable :
Address:
City:
Province:
Postal Code:
Phone:
Nominee's Signature:	___________________________________________
Attach supporting documentation as described in the "Nomination Procedures".
Your name (sponsor) :
Address:
City:
Province:
Postal Code:
Phone #:
Signature:	___________________________________________
Name of reference for nominee :
Address:
City:
Province:
Postal Code:
Phone #:
Where did you hear about the Heart Beat Awards?
Please send nominations to: HEART BEAT AWARDS NOMINATION COMMITTEE, c/o Public Health and Long-Term Care Branch of the City of Ottawa, 100 Constellation Cres., 7th Floor East, Ottawa ON., K2G 6J8 Back to the News Section