City of Karratha Australia Day Awards 2019 Nominations

The 2019 Australia Day Awards are brought to you by the City of Karratha with the support of Rio Tinto, Horizon Power, the Woodside-operated North West Shelf Project and Woodside Energy Limited

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* 1. Please ensure you read the selection criteria at karratha.wa.gov.au/australia-day prior to completing this form. Nominations close at 4pm, Friday 30 November 2018.

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* 2. Please tick which category your nominee will be nominated for:

Citizen of the Year

Young Citizen of the Year

Environmental Award

Community Spirit Award

Community Service Award

Community Event/Activity of the Year

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* 3. NOMINEE (the person you are nominating)

Title

First Name

Last Name

Gender

Organisation / Position

Address

Suburb

Postcode

Tel (H)

Tel (M)

Tel (W)

Age/DOB

Aboriginal/Torres Strait Islander

In what area has your nominee excelled?

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* 4. Please upload a high resolution photo of the nominee

File size limit is 16 MB. Email additional photos or video footage for the awards presentation to events@karratha.wa.gov.au

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

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* 5. Tell us about your nominee: Please provide as much detail as you can and consider the selection criteria.

What is the significant, long term or voluntary contribution of the nominee?

How has the nominee contributed to the betterment of the community?

In what way has the nominee been a role model to the community?

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* 6. Optional: Upload supporting documentation for your nomination

(references, biographies, newspaper articles etc)

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

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* 7. REFEREE (we will contact the referee for further information on your nominee)

Title

First Name

Last Name

Organisation/Position (optional)

Tel (H)

Tel (M)

Tel (W)

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* 8. NOMINATOR (your details)

Title

First Name

Last Name

Gender

Organisation/Position (optional)

Address

Suburb

Postcode

Tel (H)

Tel (M)

Tel (W)

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* 9. Is your nominee:

A family member

Colleague

Friend

Other (please specify)

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* 10. Do you wish for your nominee to know you nominated them?

Yes