Celebrating Community Nomination Form

Shire of Mundaring
Citizenship Awards 2020
Nomination Form

Shire of Mundaring is calling for nominations for Shire of Mundaring Citizenship Awards 2020.

Nomination Categories

Rising Star (under 25) -  Recognises a young individual or group of young people who have made a significant contribution to their local community.

Inspirational Volunteer - Recognises an individual or group who, through a volunteering role, has made an outstanding contribution to the local community.

Access Mundaring - Recognises an individual or group who are making a difference by creating a more accessible and inclusive Shire of Mundaring.

Long Service - Recognises an individual or group who are community champions, having continuously served their community for an excess of ten years.

A panel will consider all nominations and select one recipient per category to receive a Shire of Mundaring Citizenship Award.

Shire of Mundaring Citizenship Award

This award recognises individuals and groups who have made a noteworthy contribution to their community within the current year, or given outstanding service to the community over a number of years through active involvement.

The awards will be presented to the recipients at the Australia Day Citizenship Ceremony on Tuesday 26 January 2021.

Nominator Details

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

Eligibility Criteria

  • Nominees must not have been a recipient of an award in the past five years.
  • Sitting members of State, Federal and Local Governement are not elegible.
  • The Nominee must be an Australian Citizen.
  • The Nominee must be a resident of the Shire of Mundaring.

Nominee Details

Nomination Category *

Full Name *
Address *
Phone (Home)
Phone (Work)
Phone (Mob)

Referee Details

This person must be able to directly comment on the nominee’s contribution to the community.

Full Name

Phone (Home)
Phone (Work)
Phone (Mob)

Reasons for Nomination

Please address one or more of the selection criteria below.

Positive impact on the community:
Contribution and achievements:
Demonstrated leadership/inspiring qualities:
Any other information relevant to the nomination:

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?

Nominations close Friday 20 November 2020.
Please direct any queries to Monika Thomas:

PH: 9290 6604
Email: padcs@mundaring.wa.gov.au

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