Order of Manitoba
Nomination Form

I would like to nominate the following individual for the Order of Manitoba:

Name:
Address:		City:
Province:		Postal Code:
Telephone:
Home:		Business:

I feel that my nominee has demonstrated excellence and achievement, and has made a mark on our province and our people in the following ways:

Please attach any additional information regarding your nominee's accomplishments, along with up to three names of reference, and send it to the address below.

My name is:
Address:		City:
Province:		Postal Code:
Telephone:
Home:		Business:

If you would prefer, a written application is available from the:

Secretary, Order of Manitoba Advisory Council
Room 338
Legislative Building
Winnipeg, Manitoba
R3C 0V8

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