CITIZEN OF THE YEAR AWARDS

Required fields are marked with an asterisk (*).

AWARD CATEGORY

Please select which Award categories that you are nominating in *

CITIZEN OF THE YEAR AWARD
YOUNG CITIZEN OF THE YEAR AWARD
CORPORATE CITIZEN OF THE YEAR AWARD
COMMUNITY GROUP OF THE YEAR AWARD
COMMUNITY EVENT OF THE YEAR AWARD

I WOULD LIKE TO NOMINATE (The Nominee)

NAME *

POSITION/ORGANISATION *

PRIVATE ADDRESS *

PHONE (MOBILE) * Enter your phone number without spaces

DATE OF BIRTH *

Day Month Year

EMAIL ADDRESS *

COUNTRY OF BIRTH

IS THE PERSON BEING NOMINATED AN AUSTRALIAN CITIIZEN? *

REASON FOR NOMINATION

HOW HAS THE PERSON/ORGANISATION CONTRIBUTED TO THE COMMUNITY *

PLEASE LIST ANY OTHER SIGNIFICANT CONTRIBUTIONS AND/OR ACHEIVEMENTS

REFEREES

1. NAME OF REFEREE * Written references are helpful and one or two may be attached to the application whom the Selection Panel may contact if it wishes to find any additional information

ADDRESS *

POSTCODE

PHONE (PRIVATE)

PHONE (BUSINESS)

WHAT IS THE RELATIONSHIP OF THE REFEFREE TO THE NOMINEE

2. NAME OF REFEREE

ADDRESS

POSTCODE

PHONE (PRIVATE)

PHONE (BUSINESS)

WHAT IS THE RELATIONSHIP OF THE REFEREE TO THE NOMINEE

CONFIDENTIAL INFORMATION

Do you wish for your name to remain confidential from the person you are nominating? *