New Community Awards Nomination Form

Citizen of the YearYoung Citizen of the YearCommunity Event of the YearCommunity Group of the YearAccess and InclusionSports Person of the YearArts Person of the Year

Name of nominee*

First NameLast Name

Name of event*

Name of community group*

Nominee's address*

Address

Address line 2

SuburbState

Postcode

Nominee's age or date of birth

Nominee's email*

example@example.com

Nominee's mobile*

Please enter a valid phone number.Format: 0400-000-000.

Nominee's phone (after hours)

Please enter a valid phone number

Nominee's phone (business hours)

Please enter a valid phone number

YesNo

The nominee must live in Mitchell Shire and be an Australian Citizen to be eligible for this award.

In 200 words or less, tell us why you think the nominee should receive an award*

Provide as much detail as you can. Words0/200

Supporting documentation (optional)

Please attach any additional details or documentation to support your nomination. Maximum file size 10MB.

Volunteering roles

Rows	Group/organisation	Position held/role	Length/year of service
Line 1
Line 2
Line 3
Line 4
Line 5

Memberships

Rows	Group/organisation	Position held/role	Length/year of service
Line 1
Line 2
Line 3
Line 4
Line 5

Other activities

Rows	Organisations	Activities	Length/year of service
Line 1
Line 2
Line 3
Line 4
Line 5

Name*

First NameLast Name

Address*

Address

Address line 2

SurburbState

Postcode

Email*

example@example.com

Mobile*

Please enter a valid phone number.Format: 0400-000-000.

Phone (after hours)

Please enter a valid phone number

Phone (business hours)

Please enter a valid phone number

Organisation represented (if any)

Personal information collected by Council is used for municipal purposes as specified in the Local Government Act, 2020 or other relevant legislation. The personal information will be used solely by Council for these purposes and or directly related purposes. Council may disclose this information to other organisations, if required by legislation.

The collection and handling of personal information is conducted in accordance with Council’s Privacy Policy. Please refer to Council's Privacy Statement and Privacy Policy on our website for further information about your rights.

I confirm that I have provided Mitchell Shire Council with true and accurate informationI understand my information is collected in line with Council's Council's Privacy Policy

Signature*

Community Awards Nomination Form

About the nominee

Your details

Collection of information