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Niagara Impact Awards Nomination Application

Nominee information

The information you provide here will help assess the eligibility of the nominee for recognition. Please fully complete the form with accurate and detailed information.

Upon receipt of your application, Niagara Region will contact the nominee to tell them they have been nominated for a Niagara Impact Award. All nominees are required to consent in writing to their nomination and to public disclosure of their full names as part of the promotion and recognition. They must also confirm that the information provided herein is accurate for their nomination to proceed. Subject to the nominee’s consent below, select information contained herein may be used by Niagara Region to promote the Niagara Impact Awards program.
1. Nominee information
This question requires a valid email address.
Is the nominee aware that they're being nominated for a Niagara Impact Award? *This question is required.