Ashcroft/Cache Creek Rotary Club

2017 Citizen of the Year Application

APPLICATION FOR NOMINATION

1. Name of nominee __________________________________________________

2. Address of nominee ________________________________________________

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3. Telephone Number ________________________________________________

4. Name of person submitting application _________________________________

5. Telephone No. (Residence) _________________ (Business) _______________

(Cell) ___________________ (email)_______________________________

6. Use attached sheet to submit a short summary of reasons you feel this person should
receive this award: (Attach an additional sheet of paper, if necessary.)

Please submit application to: Ashcroft/Cache Creek Rotary Club,

Box 11, Ashcroft, BC V0K 1A0 Phone 250 682 3232 Email theresatakacs@hotmail.com

This award is kept as a surprise to the recipient. A ceremony and reception will be held at a date
convenient for the recipient and the committee.

Short Summary
Short summary (If applicable, please include names of groups and organizations nominee has served on
along with positions held, if any.)

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