City of Karratha Long Service Recognition Award

Nomination Form

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* 1. Name of nominee.

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* 2. Nominated by (your name)

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* 3. Your email and phone number.

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* 4. Does the nominee reside within the City of Karratha?

Yes

No

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* 5. Nominee has been a volunteer administrator or office bearer in a recognised sports club / association located within the City of Karratha?

Yes

No

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* 6. Years of continuous service.

20 Years

25 Years

30 Years

35 Years

40+ Years

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* 7. Committee position or positions held

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* 8. Name of Club / Association.

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* 9. Can you provide a signed letter of support from the club / association endorsing their nomination?

PLEASE EMAIL SIGNED LETTER OF ENDORSEMENT TO christy.reed@karratha.wa.gov.au

Yes

No