Celebrating Community Nomination Form

Shire of Mundaring
Celebrating Community 2017
Nomination Form

Shire of Mundaring is pleased to celebrate the significant and outstanding contribution of community members by accepting nominations for both Celebrating Community and Citizenship Awards.

Shire of Mundaring will formally recognise the achievements of nominees at a celebratory high tea to be held on Sunday 3 December 2017 at 10am.

Citizenship Awards will be presented at an event to be held on Australia Day, Friday 26 January 2018, in the categories below.

Nomination Categories

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

Inspirational Volunteer - individual/group who through their volunteering role have made an outstanding contribution to the local community.

Access Mundaring - Recognises an individual or group making a difference to create a more accessible and inclusive Shire of Mundaring.

Long Service - an individual or group who have been community champions and continuously served their community for in excess of ten years.

Your 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 within 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 Tuesday 31 October 2017.
Please call Tracey on 9290 6678 or email ga@mundaring.wa.gov.au with any questions.

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