Surname:

Other Names:

Address:

Telephone:

Date of Birth:

Age:

Does the nominee currently live and/or work in Kempsey Shire/Macleay Valley?

Yes      No

Is the nominee an Australian citizen?

Yes      No

Will the nominee be aged 26 years of over on 26 January 2011?

Yes      No

Nominee's past and present membership of community / sporting / professional bodies

Refer to Page 3 of the Guidelines and Criteria (pdf 111 KB) for information.

Photograph of the nominee - ONLY required for Citizen of the Year nominations

Provide a photograph of the nominee. Images must be either:

6" x 4" photo (Mail to: Kempsey Shire Council, PO Box 3078, West Kempsey, Attention: Mel Booth)

Passport size photo (Mail to: Kempsey Shire Council, PO Box 3078, West Kempsey, Attention: Mel Booth) OR

High resolution digital photograph (email: mel.booth@kempsey.nsw.gov.au) OR

You are unable to supply a photograph at this time..

The recipient’s full name must be printed on the back of paper-copy photos.

Additional material including photographs, media articles and/or supporting references may be emailed to mel.booth@kempsey.nsw.gov.au - limit of 2 additional pages.

Please refer to the Guidelines and Criteria (pdf 111 KB) and provide a statement that addresses the following questions.

In what role(s) or area(s) has the nominee excelled or made a contribution?

Please describe the nominee's outstanding service or positive contribution.

How has the nominee's contribution and/or service benefited the community?

Please detail any other achievements or contributions made by the nominee.

How has the nominee's contribution been recognised elsewhere?

Contact No. 1

Name:

Position:

Relationship to Nominee:

Address:

Telephone:

Contact No. 2

Name:

Position:

Relationship to Nominee:

Address:

Telephone:

I have read the Nomination Guidelines and Criteria.

I have addressed al the Selection Criteria.

The information provided in this nomination is accurate.

Supporting material, including references and media are attached.

I have supplied a high resolution photograph of the nominee in the correct format (only required for Citizen of the Year nominations)

Yes      No

Total number of pages for this nomination, including this nomination form:

Surname:

Other Names:

Address:

Telephone:

Organisation (if any):

Email:

Date: