APPLICATION FORM FOR REEBOK HUMAN RIGHTS AWARD

PLEASE SEND ALL NOMINATION COMPONENTS TO: 
The Reebok Human Rights Award Program
Reebok International Ltd.
1895 J.W. Foster Blvd., Canton, MA 02021 U.S.A.

FOR MORE INFORMATION, CONTACT THE REEBOK HUMAN RIGHTS PROGRAM: 
tel: 781-401-4910
fax: 781-401-4806 
email: humanrights@reebok.com
website: www.reebok.com/humanrights

CANDIDATE 

Name:

Date of birth:

Street/P.O. Box: 

City: 

State/Province: 

Country: 

E-mail: 

Phone (work): 

Phone (home): 

FAX: 

NOMINATOR

Name: 

Street/P.O. Box: 

City: 

State/Province: 

Country: 

E-mail: 

Phone (work): 

Phone (home): 

FAX: 

LETTERS OF REFERENCE (may be sent separately)

Name/Organization 1: 

Phone: 

Fax: 

E-mail: 

Name/Organization 2: 

Phone: 

Fax: 

E-mail: 

Name/Organization 3: 

Phone: 

Fax: 

E-mail: