<p> Prime Minister’s Awards for Teaching Excellence 2014 Nomination Form</p><p>All personal information collected in the nomination package is protected under the Privacy Act. It is used by Industry Canada to process the nominations and for related statistical studies. Participation is voluntary. Information will be stored in Personal Information Bank IC PPU 001. Nominees may access, request correction of, or have a notation attached to the information about them by contacting the Prime Minister’s Awards (PMA) Office at 613-991-4255 or [email protected]. Each award recipient’s name, school, community, and work contact information are included in short biographies published for the media and online at www.pma.gc.ca. Award recipients’ photographs may also be used in promotional and information materials by the Prime Minister’s Awards for Teaching Excellence.</p><p>Nominee's Personal Information (Please provide names as they should appear on the certificate) □ Dr. □ Mr. □ Mrs. □ Ms. Last Name ______First Name ______Home Address ______City/Community ______Prov./Terr. ______Postal Code ______Tel. (H) ______E-mail (H)______Tel. (W) ______E-mail (W) ______</p><p>Is the nominee a Canadian citizen or permanent resident? □ Yes □ No At the time of nomination, does the nominee teach a minimum of 2.5 days per week? □ Yes □ No Does the nominee use information communications technology (ICT)in his or her classroom? □ Yes □ No Is this a team nomination? □ Yes □ No Does the nominee self-identify as an Aboriginal teacher? □ Yes □ No At the time of nomination, does the nominee teach at a First Nation school or in an Inuit region? □ Yes □ No</p><p>Nominator Information (To be completed by either an individual nominator or a representative of a nominating group) □ Dr. □ Mr. □ Mrs. □ Ms. Last Name ______First Name ______Organization Represented (if applicable) ______Address ______City/Community ______Prov./Terr. ______Postal Code ______Tel. (H) ______Tel. (W) ______Fax ______E-mail ______</p><p>Principal/Supervisor Information □ Dr. □ Mr. □ Mrs. □ Ms. Last Name ______First Name ______Tel. (W) ______E-mail ______</p><p>Nominee's School Information (Cash awards will be shared with this teaching institution if the nominee is chosen for a Certificate of Excellence.)</p><p>School Name (or school board if teacher is not affiliated with a particular school) ______Address ______City/Community ______Prov./Terr. ______Postal Code ______Tel. ______Fax ______E-mail ______Website ______Teacher's Website at school, if different ______Grades currently taught ______Subject(s) currently taught ______First nation school? □ Yes □ No Signatures</p><p>Nominator I, the nominator, hereby affirm that all the information contained in this nomination package is, to the best of my knowledge, complete and correct and that the nominee upholds the highest standard of the teaching profession. </p><p>Signature of Nominator ______Date ______</p><p>Nominee I, the nominee, hereby affirm that, to the best of my knowledge, all the information contained in this nomination package is complete and correct. By signing this form, I authorize the Prime Minister’s Awards office to conduct a verification of the information provided in this nomination package. I understand that the best teaching practices of national level Prime Minister’s Award recipients will be published online and I give my release for that purpose should I be chosen for this award. I have also read the Prime Minister’s Awards recipient Code of Conduct found on the program website at www.pma.gc.ca and understand that failure of abide by these standards, if chosen, could result in the revocation of this award. </p><p>Signature of Nominee ______Date ______</p><p>Principal/Supervisor I, the principal/supervisor, affirm that all information contained in this nomination package is, to the best of my knowledge, complete and correct. By signing this form, I, the principal/supervisor, have read and support this nomination.</p><p>Signature of Principal/Supervisor ______Date ______</p><p>For PMA Program Office Use Only Is a copy of the completed nomination checklist included in the nomination package? □ Yes □ No Is a copy of the teacher's certificate included? □ Yes □ No Is the teacher’s certificate valid? □ Yes □ No Does the nominee have at least three years experience teaching in primary or secondary schools? □ Yes □ No</p><p>If applicable, is evidence of the nominee’s Aboriginal status included in the nomination package? □ Yes □ No Is the nomination text included in the nomination package? □ Yes □ No Are the three letters of support included in the nomination package? □ Yes □ No Does the nominee meet all criteria to be eligible for a Prime Minister’s Award? □ Yes □ No</p><p>For more information, please contact the Prime Minister Awards office at 613-991-4255 or [email protected]. </p>