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)

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)

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?

Skip navigation links
About Council
Strategic Plans
Policies & Local Laws
News & Publications
Awards & Recognitions
Citizenship Ceremonies
Rates & Services Proposal
Skip navigation links
Building & Planning
Fire & Emergency
Infrastructure & Works
Public Health
Ranger Services
Waste Management
Skip navigation links
Access & Inclusion
Arts & Culture
Children, Seniors & Youth
Community Directory
Community Events
Skip navigation links
Business & Tourism
Business Directory
Mundaring Demographics
Population Forecasts
Economic Profile

A Sense of Space, a Sense of Place. Sitemap  |   Copyright Shire of Mundaring 2016