City of Newburgh Human Rights Commission

83 Broadway, Newburgh, NY 12550

City of Newburgh - Human Rights Commission

Human Rights Hero Nomination Form

NOMINATION MATERIALS MUST BE RECEIVED NO LATER THAN
4:00 PM, MONDAY, DECEMBER 4, 2023.

First Name of Nominee

Last Name of Nominee

Email address of Nominee

Phone number of Nominee

Birthdate of Nominee

Nominator information: Please enter your own information here.

Your name

Email address

Phone number

In what capacity do you know the nominee?

What Human Rights category does the nominee serve? (Select only one)

Disability

Education

Employment

Gender/Sexuality

Health

Housing

Immigration

What organization is the nominee affiliated with (If any)?

Nominee Education: (schools/degrees/specialties)

Tell us about the Nominee. Provide a short factual description of the nominee including: brief career background, description of current organization (if any) and what type of human rights work they do.

Describe why this Nominee should be a City of Newburgh Human Rights Hero? Include the Nominee’s role and contribution to the human rights movement.

Please submit or attach the following:

Humanitarian Service History no more than three pages
Any other information you believe would be relevant

Upload Humanitarian Service History (no more than three pages):

Click Here to Upload

Upload other relevant documents:

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TRANSPARENCY

Let us know if you or your nominee has an affiliation with the City of Newburgh. This is for transparency only; the panel will review your application without bias. Read our full Conflict of Interest policy (https://ecode360.com/10870568).

Confirmation and Consent affirmation – I, the nominator, attest to the following:

The information to be true to the best of my knowledge.
Nominee consents to being nominated.

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

Today's Date