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, 29 November 2019.

I have read the selection criteria

I have not read the selection criteria

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* 2. Please select the 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)

Date of Birth (00/00/000)

Aboriginal/Torres Strait Islander

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* 4. In what area has your nominee excelled?

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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 nomination)

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:

Family member

Colleague

Friend

Other (please specify)

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

Yes

City of Karratha Australia Day Awards 2019 Nominations

Question Title

* 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, 29 November 2019.

Question Title

* 2. Please select the category your nominee will be nominated for:

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* 3. NOMINEE (the person you are nominating)

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* 4. In what area has your nominee excelled?

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

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* 6. Optional: Upload supporting documentation for your nomination

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

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* 8. NOMINATOR (your details)

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* 9. Is your nominee:

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

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