Australia Day awards form

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Record ID

Nominee details

Details of the person or group being nominated

Is the nominee an individual or group?*

Individual

Group

Nominee name*

Given Name Surname

Group name*

Approximate age*

Nominee Address

Street Address City Postcode

Nominee's Phone*

Please tell us why you are nominating this individual/group.*

Please add any other relevant background details.

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Name

Contact Number

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Submitters name*

Given Name Surname

Submitter's Phone*

Submitter's Email*

Submitter's Address

Street Address City Postcode

Conditions of entry

Self nominations will not be accepted.
Supporting evidence may be attached to the nomination form.
Incomplete nomination forms will not be considered.
Nomination forms must be received by 5pm Friday 15 December 2023.
The nominee must be an Australian Citizen and reside in the Northern Grampians Shire.
The selection panel will make their decisions based on the criteria for each award and the information provided with the nomination forms.
The selection panel reserves the right to consider any nomination for any award category.
The decision of the selection panel is final and no correspondence will be entered into.
In the event that no nominations are received in any of the categories, the selection panel reserves the right to grant the award to a group, event or citizen of its choice.
All nominees and nominators will receive an invitation to the award ceremony at which the Mayor and Australia Day Ambassador will present the awards.

I have read and agree to the conditions above

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