2020 Glenorchy Citizen and Young Citizen of the Year Nomination Form

2020 Glenorchy Citizen and Young Citizen of the Year Nomination Form

Applications close: Friday 15th November 2019
Nomination for (please tick):

Glenorchy Citizen of the Year Glenorchy Young Citizen of the Year
SECTION 1

Details of person being nominated
Name

First Name Last Name

Address

Email
example@example.com
Phone Number

Area Code Phone Number
Does the nominee currently live and/or work within the Glenorchy Local Government Area?

Yes No
Is the nominee an Australian Citizen?

Yes No
Will the nominee be aged 26 years or over on 26 January 2020?

Yes No
Why are you nominating the person for this award?
Please provide a rough estimate of the number of hours the nominee has contributed, over and above any associated normal employee duties.
Please outline the benefit to the community from the nominee's service/contribution
Who has benefited most from the work of the nominee (e.g. whole of community, specific group/s, individual/s etc.)?
Please detail any outstanding efforts/contributions to the community, region, state or nation.
Please outline any significant personal effort/achievements.
Please detail any (other) outstanding achievements by the nominee.
Has the nominee worked as part of a team and if so what has been their role?
Has the nominee received assistance from Council, Government or grant providers?
Has the nominee had to overcome any difficulties/hurdles?
Has the nominee's contribution been recognised elsewhere? Please detail other recognition including publicity.
Please upload any supporting documentation here

Browse Files

Cancel of
Referee No. 1 details:

First Name Last Name
Relationship to nominee (e.g. employer, friend, fellow committee member etc.)

Address

Address

Email
example@example.com
Phone Number

Area Code Phone Number
SECTION 2
Please use this check list to ensure that your nomination is complete.

I have read the Nomination Guidelines and Criteria I have addressed all the Selection Criteria The information provided in this nomination is accurate Supporting material, including references and media information, are attached
Details of person submitting the nomination.

First Name Last Name
Relationship to nominee e.g. employer, friend, fellow committee member etc.

Address

Email
example@example.com
Phone Number

Area Code Phone Number
Organisation (if any)
Signature

Browse Files

Cancel of
Date

Month Day Year
Date Date Picker Icon
PRIVACY STATEMENT: Glenorchy City Council collects personal information to promote the Citizen of the Year Awards and supply of information is voluntary. Council will not use personal information for any other purpose. Access to the information is restricted to Council Officers and other authorised people. Council is to be regarded as the agency that holds the information. Application may be made to access or amend personal information held by Council.
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