Changing the Way Canadians Think About Disability

Canadian Disability Hall of Fame Nomination Form

Application Submitted by
Name
Street
City Province
Postal Code Phone
Email Fax
Prefered Method of Communication Phone    Email    Fax

Please submit the name of the following person to the Selection Board for consideration for induction into the Hall of Fame.

Nominee Information
Nominee
Category
Street
City Province
Postal Code Phone
Email Fax
Prefered Method of Communication Phone    Email    Fax