Nominate

Council*

Nominee

(the person/organisation you would like to nominate)

Award Category*

Name*

Please double check this shows the name of the person/organisation you want to nominate and it has not been autofilled by your device.

Given Name Family Name

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What is the nominee's sex?

Female
Male
Prefer not to say
Other (you may specify below)

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Other

What is their gender?

Man or Male
Woman or Female
Non-binary
Other (you may specify)
I don't know

Other (gender)

How do you know the person you're nominating?*

Age

Is it a group or event?*

Group/Event Name*

Name

Address (Residential/Work)*

The person/organisation you are nominating must reside or work primarily within the local council area for which you are submitting the nomination. If you do not have an exact address, you may provide the state, suburb, and postcode to help us verify that the nominee is in the correct Local Government area.

Street Address Suburb State Postcode

Group/Event Representative Name*

Given Name Family Name

Email

Phone

What type of group is it?

Community group or association
For-profit business
Government agency
Nonprofit or charitable organisation
Religious or faith-based organisation
Social enterprise

What type of event is it?

Check all that apply.

Advocacy for Social Inclusion
Cultural Diversity Celebration
Fundraising Event
Mental Health Awareness Event
Sports and Recreation Program
Youth Mentoring Program
Other (please specify below)

Other (please specify)*

What was the total amount of funds raised?

In which field/sector(s) has the nominee made the most significant contributions?*

Please select no more than 3.

Other (please specify below)*

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Is the person being nominated an Australian citizen?

Yes
No

Which organisation has the nominee been most involved in or contributed the most work to?

E.g. St John WA, Surf Life Saving, etc. Please add additional organisations in separate fields by clicking the ‘+’ icon to create a new field for each one.

Reason for nomination*

Nominees for the group/event award category must demonstrate community engagement and meet any or all of the following criteria:
- Group/event that creates community engagement.
- Group/event that creates initiatives for new employment.
- Created significant initiative that brought positive change.

How has the nominee made a significant contribution to the local community?*

Please include specific examples of what they have done to positively impact the community. Be sure to highlight any unique or innovative approaches they have taken to address community needs or challenges.

How has the nominee demonstrated leadership on a community issue, or enhancement of community life?*

Please include volunteering, community involvement, leadership roles, and any other ways in which the nominee has actively worked towards improving their local community.

Has the nominee's contribution been recognised elsewhere?

If the nominee has received recognition for their contributions elsewhere, please provide details. This may include any awards they have won, any media coverage they have received, or any public recognition they have been given.

Attachments

Please attach any relevant documents or materials that support this nomination, such as letters of recommendation, news articles, or photos – maximum five A4 pages, minimum font size 10 point.

Drop files here or

Max. file size: 2 MB.

Where did you hear about these awards?*

Other (please specify)*

Additional information

We appreciate you completing the following information as it is important to help us ensure that everyone in the community is provided an opportunity for inclusion and recognition.

Is the person of Aboriginal or Torres Strait Islander origin?*

No
Yes
I don't know

In which country was the person born?*

If you are unsure, please type 'I don't know'.

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In which country was the person born?*

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OLD Does the person speak any language(s) other than English at home?

No, English only
I don't know
Yes (specify)

Which language or languages does the person speak at home?*

Please add additional languages in separate fields by clicking the ‘+’ icon to create a new field for each one. If you are unsure, please type 'I don't know'.

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Which language or languages does the person speak at home?*

Check all that apply.

Other (please specify below)*

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What is the person's ancestry?*

Please add additional ancestry in separate fields by clicking the ‘+’ icon to create a new field for each one. If you are unsure, please type 'I don't know'.

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What is the person's ancestry?

Other (please specify below)*

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What is the person’s ancestry? (For example: English, Scottish, South African, Italian, Malaysian, Vietnamese). Provide more than one ancestry if necessary.

Nominator

(Your Details)

Name*

Given Name Family Name

Email (A confirmation email will be sent to this email address)*

Phone

Do you want to remain anonymous to the nominee?

Yes
No

Address

Street Address Suburb State Postcode

Referee/Alternate Person

Please include anyone that may be able provide additional information to support this nomination. Name along with a contact email or number is fine.

I give permission for the Australia Day Council of Western Australia to submit this nomination to other recognition programs such as the Australian of the Year Awards

Yes

Do you know someone who makes your community a better place?

Nomination Form

Nominee

Additional information

Nominator

Principal Partner

Media Partners

Print Partner

Proudly presented in partnership with Local Councils across Western Australia

Assisted by the Australian Government through the National Australia Day Council