Online Form - Community Leadership Award

Presented to groups or individuals that have made a significant contribution to the local community. They will have enhanced community life, have been involved in a significant initiative which has brought about positive change and/or significantly contributed to achieving connections and inclusion within the community

About the person or group, you are nominating:

Please tick the boxes below to show that your nomination meets all the following criteria:*

This person or group operates in the Town of Bassendean
I am not the person, or a member of the group being nominated.
I understand the assessment of the nominee will be made based on the information that I provide in this application.
I understand that a copy of this application will be shared with the Nominee.
I have read and agree with the Terms and Conditions.

Name (One Person or Group only)*

Address*

Phone Number*

Email Address*

Has the nominee's contribution been recognised elsewhere?

Reason for nomination:

In this section, please describe clearly and to the point what the nominee has done and why you think they should be recognised. Tell us what you know and what you think is noteworthy about your nominee’s service and achievements.

What significant contribution has this person or group made: to enhancing community life by being involved in a significant initiative which has brought about positive change and/ or contributed to achieving connections and inclusion within the community?*

Please provide your details:

Your Name*

Address

Street Address:

City:

State:

Post Code:

Country:

Phone Number*

Email Address*

Where did you hear about these awards?*

Terms & Conditions

Thank you for taking the time to complete your nomination.

Please accept the Terms and Conditions to continue:

Acceptance*

I have read and agree to the Terms and Conditions in the link above

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