City of Karratha Australia Day Awards 2018 Nominations

Important:

Please ensure you read the selection criteria at karratha.wa.gov.au/australia-day prior to completing this form. Nominations close at 5pm on Thursday 7 December 2017.

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

Citizen of the Year

Young Citizen of the Year

Community Service Award

Environmental Award

Community Spirit Award

Community Event / Activity of the Year

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* 2. NOMINEE (the person you are nominating)

Title

First Name

Last Name

Gender

Organisation/Position (optional)

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

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

Choose File

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* 4. Tell us about your nominee: Please provide as much detail as you can and consider the selection criteria. You can email additional pages and supporting material.

Why have you chosen this nominee?

How has the nominee contributed to the community?

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

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* 5. Optional: Upload supporting documentation to support your nominee

(references, biographies, newspaper articles, etc)

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

Choose File