Australia Day Awards Nomination Form

Form assistance

For help completing this form or for more information on the conditions of entry, guidelines and selection criteria, please visit www.tr.qld.gov.au/australiaday.

Nominee type

Is the nominee a person or organisation? *

The nominee is a person.The nominee is an organisation.

Nominee details

Organisation name

Organisation name *

Name

Title *

First name(s) *

Last name *

Age

Age(required for junior awards)

Contact information

Phone number

Address

Street address

Suburb

State

Postcode

Postal address

Is the postal address different to the street address?

YesNo

Postal address

Suburb

State

Postcode

Additional details

Is the nominee an Australian citizen? *

YesNoUnknown

Is the nominee aware they have been nominated?

YesNo

Would the nominee accept the award if selected?

YesNoUnsure

Nominee photo

While it is not essential, if you have a photo of the nominee this can be included as part of the nomination.

Attach photo of nominee

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Australia Day Awards Nomination Form

Award category

Please select the award category for the nominee *

Citizen of the year (over 26 years of age)Young citizen of the year (under 26 years of age)Cultural awardSports award - junior (Nominee is not older than 18 years of age as at January 26 in the award year)Sports award - senior (Nominee is older than 18 years of age as at January 26 in the award year)Community groupCommunity eventCitizen of the year - Aboriginal & Torres Strait Islander

District details

Australia Day Awards Nomination Form

Reason for nomination

Nominee achievements

Achievement #1 *

Achievement #2

Achievement #3

Achievement #4

Achievement #5

Nominee merit

In 25 words or less, tell us why your nominee deserves an Australia Day Award *

Nominee background

Please tell us about your nominee in 400 words or less *

Optional attachments

Other information (press clippings etc) may be uploaded to further illustrate the nominee's achievements

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You may upload multiple files by hitting the 'Upload File' button for each file.

Australia Day Awards Nomination Form

Details of the nominating person

Name *

First name (s) *

Last name *

Phone number

Organisation represented (if applicable)

ABN/ACN

Address of the person submitting the nomination

Street address

Suburb

State

Postcode

Privacy

Toowoomba Regional Council is collecting your personal information in accordance with the Information Privacy Act for the purpose of assessing and awarding Australia Day awards. The information provided in this nomination will be accessed by authorised members of the relevant Australia Day Committees and may be shared with other government agencies to acknowledge achievements. The award recipient’s name and accomplishments may be published on the Council’s web page and provided to the media.

Declaration

I understand and acknowledge that:

The information provided in this application is true and complete to the best of my knowledge.
Council may refuse this application if it becomes evident that any information or supporting documents provided are incomplete or false.
I approve of the information that has been provided in this application.
I acknowledge Queensland State Laws will accept this communication as containing my signature within the meaning of the Electronic Transactions (Queensland) Act 2001.

Signature

I agree with the declaration and privacy statement *

Nominator's full name

Date

Form process

Once you click 'Submit', you will receive an automatic confirmation of your application on the screen. Alternatively you can choose to download the filled in form or have the form emailed to yourself once you click the 'Submit' button.

The nomination will be forwarded to the relevant community Australia Day committee for their consideration.

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