Candidate Information

Full Name

Preferred Name (if applicable)

Date of Birth (DD/MM/YYYY)

Date

Cellphone Number*

Home Phone Number (if different from above)

Email

Address

Address 1

City

ZIP / Postal Code

State / Province

Country

Indigenous Nation/Community/Land Claims Settlement

Current Role (if a student, please name area of study)

Current Organization (if a student, please name school)

Self Identification*

First Nation

Inuit

Métis

Has the Candidate attended the PDAC Convention before?

Yes

No

If yes, what year(s)?

Nominator Information (If applicable. Do not complete if candidate is nominating themselves)

Nominator Name

Nominator Phone Number

Nominator Email

Nominator Title/Role

Nominator Organization/Community Name

Reference Information

Reference #1 – Industry Reference (this reference must be able to speak to the candidate’s demonstrated or proven interest in the mineral industry). A nominator can serve as one reference.

Reference Name*

Reference Phone Number

Reference Email

Reference Title/Role

Reference Organization

Reference Nation/Community/Land Claims Settlement (if applicable)

Reference has consented to be contacted in relation to this application

Yes

No

Reference #2 – Additional Reference (preferably a member of the Candidate’s Nation/community). A nominator can serve as one reference.

Reference Name

Reference Phone Number

Reference Email

Reference Title/Role:

Reference Organization:

Reference Nation/Community/Land Claims Settlement (if applicable)

Reference has consented to be contacted in relation to this application.

Yes

No

Estimated Travel Costs

Please provide an estimate of the expenses the candidate may incur in travelling to and attending the PDAC convention.

Travel to Toronto

Estimated Cost ($)

Please specify your method of travel

flight, bus, driving, etc.

Additional Expenses

Estimated Cost ($)

Total

Estimated Total Cost ($)

Additional information about expenses (optional)

Candidate Actions

Please describe the candidate’s demonstrated or proven interest in the mineral industry. Employment and volunteer experience can be included.

Please describe how the candidate shows commitment to their community, as demonstrated by actions such as participation or volunteerism.

Additional information you would like to provide (optional)

Attendance Confirmation

Select choices

I, the [candidate/nominator], understand that the PDAC will provide funds to support travel of the successful ambassadors to the convention, and that the remainder of expenses must be covered by the candidate or a third party.

I, the [candidate/nominator], confirm that the candidate is available to attend the entire duration of convention (Sunday to Wednesday).

I, the [candidate/nominator], confirm that the candidate may have their picture taken during the program and give PDAC permission to use the picture in promotional material including the PDAC website and social media, PDAC print and electronic media, and related sites.

Indigenous Ambassador Program Application Form

Please complete the application below