Citizenship Award Nomination Form

Shire of Mundaring
Citizenship Award 2016
Nomination Form

Shire of Mundaring encourages all nominators to recognise & acknowldge those in their community displaying ideals of community life and active citizenship.

The recipients will be selected from people who have made a noteworthy contribution during the current year, given outstanding service to the local community over a number of years through active involvement, have demonstrated leadership in the enhancement of our community, represent an inspiring role model or has contributed to a significant initiative which has brought positive change in the community.

Your Details

Full Name
Your Organisation Name
Phone (Home)
Phone (Work)
Phone (Mob)
Email

Eligibility Criteria

  • A person cannot receive the same award twice, but can be considered for another award.
  • Sitting members of State, Federal and Local Governement are not elegible.
  • The Nominee must be an Australian Citizen.
  • The Nominee must be a resident within the Shire of Mundaring.

Nominee Details

Nomination Type *
 
Full Name *
 
Address *
 
Phone (Home)
Phone (Work)
Phone (Mob)
Email

Reasons for Nomination

Please address one or more of the selection criteria below.

Significant contribution to the local community:
Demonstrated leadership in the enhancement of our community:
A significant initiative which has brought positive change and added value to our community:
Inspiring qualities as a role model for our community:

If you have any relevant pictures, videos or documents to support the person's nomination, please upload them below. Ensure you have permission for any photos or videos.

Parental permission is required for persons under 18.

Highlight to select multiple files while browsing.


Any other comments?





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