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City of Newburgh Human Rights Commission

83 Broadway, Newburgh, NY 12550

City of Newburgh - Human Rights Commission

Human Rights Hero Nomination Form

4:00 PM, MONDAY, DECEMBER 4, 2023.


Residence Address of Nominee

Mailing Address (if different from Residence)

Nominator information: Please enter your own information here.

Mailing Address

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

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):

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Upload other relevant documents:

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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 (

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

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

Sign Here

Choose how to sign

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