Name (Nominee):

Address: (Nominee):

Burlington, Ontario Postal Code:

Phone number (Day):

Phone number (Evng):

Nominator (Name):

Address:

Phone:

Email

How do you know the person you are nominating? (Friend, Co-worker, Agency) :

How long have you known this person?

Please give a description of why you feel this person is deserving of a vehicle?

How did you found out about our Annual Christmas Giveaway?