Online Form - Australia Day Citizenship Nominations - Australia Day 2023

Please choose one of the following:*

YOUTH AWARD - Presented to an individual under 25 years of age who has made an outstanding contribution to the local community.
CITIZEN AWARD - Presented to an individual over 25 years of age who has made an outstanding contribution to the local community.
COMMUNITY GROUP OR EVENT AWARD - Presented to a community group or organisers/committee of an event held in the Shire of Coolgardie that has made an outstanding contribution to the local community.
CORPORATE CITIZEN AWARD - Presented to a business or organisation that has made an outstanding contribution (financial or in-kind) to the community in the Shire of Coolgardie.

Name of Nominee*

Nominee Address:*

Nominee Contact Number:

Nominee Email Address:

Nominator Name:*

Nominator Address:*

Nominator Contact Number:*

Nominator Email Address:*

Reason for Nomination:*

Award recipients must meet the following eligibility criteria:

• Recipients must be; residents of the Shire; or have coordinated a community event Within the Shire; or be members of a community group whose principal activities are conducted within the Shire; or be a business or organisation that has contributed financially or in-kind to a community project or group within the Shire
• Awards cannot be granted posthumously
• Only one person (not a couple or group) may be nominated for individual award categories
• Local Government Councillors, State and Federal politicians are not eligible to receive an Award
• Sitting members of State, Federal and Local Government are not eligible.

Do you the Nominator agree to the above criteria?*

YesNo

Date