Peacemaker Nomination Form

Nominator Information
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship to Nominee
Nominator Organization Information (If Applicable)
Organization Name
Organization Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact
Email*
Primary Phone*
Office Phone
Mobile Phone*
Skype Name
What is your preferred means of communication?
- Primary Phone
- Office Phone
- Mobile Phone
- Email
- Mail
- Skype Name

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Information on the Peacemaker that you are Nominating
Name
First Last
Post Title
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Organization (If Applicable)
Organization Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Nominee Contact Information
Email*
Alternate Email
Skype Name
Primary Phone*
Office Phone
What is the best way to contact your nominee?
- Primary Phone
- Office Phone
- Mobile Phone
- Email
- Mail
- Skype Name
Mobile Phone*
Religious Affiliation:
Nationality:
Languages Spoken:

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How The Candidate Meets The Award Criteria
Please give a brief summary of the peacemaker’s work and impact within the conflict situation:
250 word limit
How does the peacemaker meet the criterion of religious motivation? Explain how the peacemaker draws upon his/her religious beliefs to shape and sustain his/her work. How has religion directly impacted his/her peacemaking approach and techniques?
250 word limit
How does the peacemaker meet the criterion of working or having worked in an area of armed conflict? Describe the nature of the conflict and the context in which the peacemaker works.
250 word limit
How does the peacemaker meet the criterion of working at risk? Describe any threats or actions taken against the peacemaker’s safety, freedom or life due to their efforts for peace. (This award is designed, in part, to help bring needed attention and thus protection to peace activists under threat.)
250 word limit
How does the peacemaker meet the criterion of being locally based? How long has she/he lived and worked in this locale? How does she/he work with the local community?
250 word limit
How has the peacemaker received promotion and/or support?: What awards has the peacemaker received? (Note that this award is not intended for individuals who have already been fortunate to receive extensive promotion and support.)
250 word limit

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Other Factors
How will this award further or enhance the peacemaker’s work for peace?
250 word limit
What about this individual has moved you to nominate her/him?
250 word limit
Please list any publications, web pages, online videos, or other media that address the work of the nominee.
250 word limit
Is there anything we haven’t asked that you think we should know about the candidate?
500 word limit

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References
Please list two references (other than the nominator) who we can speak to about the work of the nominee.
Reference 1
Name
First Last
Title
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Organization (If Applicable)
Organization Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Reference 1 Contact Information
Email*
Alternate Email
Skype Name
Primary Phone*
Office Phone
Mobile Phone*
What is the best way to contact your reference?
- Primary Phone
- Office Phone
- Mobile Phone
- Email
- Mail
- Skype Name

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Reference 2
Name
First Last
Title
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Organization (If Applicable)
Organization Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Reference 2 Contact Information
Email*
Alternate Email
Skype Name
Primary Phone*
Office Phone
Mobile Phone*
What is the best way to contact your reference?
- Primary Phone
- Office Phone
- Mobile Phone
- Email
- Mail
- Skype Name

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Optional Information
We welcome extra information. Feel free to support your nomination by including letters of recommendation, additional background such as press clippings, copies of statements by eye witnesses, anecdotes by those who have worked closely with the peacemaker, publications by or about the peacemaker, links to photos, videos, blogs and websites, etc. You may add additional narrative in the box below, or upload up to four supporting documents (uploading documents may take a few moments). If you have more than four supporting documents, please contact Michael McShane at mmcshane@tanenbaum.org.
File
File
File
File
Post Custom Field

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Nominator Information