Online Form - Lifetime Contribution to Volunteering

This award will be presented in honour of a senior individual (65+ years) who has made an exemplary life-long contribution to volunteering and who, through their volunteering, has contributed to the betterment of the Town of Bassendean community.

About the person you are nominating:

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

This person lives in the Town of Bassendean.
I am not the person 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 only) *

Address *

Phone Number *

Email Address *

Has the nominee's contribution been recognised elsewhere?

Reason for nomination:

How has this individual made an exemplary life-long contribution to volunteering? *

How, through their volunteering, have they contributed to the betterment of the Town of Bassendean community? *

Please provide your details:

Your Name *

Address

Street Address:

City:

State:

Post Code:

Country:

Email Address *

Phone Number *

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:

Terms and Conditions

Acceptance *

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

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