Nominations should be sent to Julie Payne at CJFE, 555 Richmond St. West, Suite 1101, PO Box 407,
Toronto, Ontario M5V 3B1 Canada, tel: +1 416 515 9622, fax: +1 416 515 7879, or e-mail

Name of nominee

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Address _______________________________________

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Phone: ________________________________________

Email address:

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Nominated by

Address _______________________________________

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Phone: ________________________________________

Email address:

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Note: If you need additional space for the following questions - please feel free to expand.

Provide basic biographical & professional information about the nominee ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Languages spoken by the nominee ____________________________________________________________________________________ ____________________________________________________________________________________ Describe the political persecution to which the nominee has been subjected ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ List any references about the nominee in newspapers or other media. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ List any awards or recognition the nominee has received. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Describe the impact, if any, that the nominee has had on free expression and or human rights in his or her country. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Describe what impact the award (including the $3000) and the public exposure will have on the nominee and his or her work. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________