JUNIOR CITIZEN OF THE YEAR AWARD NOMINATION FORM Young persons who have provided their time in contributing to the community during the current year and/or given outstanding service to the community over a number of years shall be eligible. Nominees must reside locally and be 25 years of age or under as at 26 January 2010 DETAILS OF NOMINEE First Name: …………………………………………………….Surname: ……………………………………………… Home Address: ….............................................................................................. Home Telephone :(
) ............................ Mobile Telephone: .............................
Age as at 26 January 2010: …………………………………………………………………………………………….
CIRCLE THE COMMUNITY FOR WHICH THE NOMINATION IS BEING MADE: WOOCOO – TIARO – HERVEY BAY – MARYBOROUGH
CONTRIBUTION/S TO THE COMMUNITY FOR WHICH THE PERSON IS NOMINATED
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SIGNIFICANT CONTRIBUTION/S AND ACHIEVEMENT/S ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................
COMMITMENT TO ACHIEVING GOALS ONGOING ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................
TO BE COMPLETED BY PERSON SUBMITTING NOMINATION You must be a local resident and not related to the nominee First Name: …………………………………………………….Surname: ……………………………………………… Home Address: ….............................................................................................. Home Telephone :(
) ............................ Mobile Telephone: .............................
Signature: ............................................ Date: ……………………………………………………... RETURN OF FORM
PLEASE POST COMPLETED FORM
Completed forms must be submitted by close of business:
Jenni Oort Executive Assistant Councillor Support Fraser Coast Regional Council PO Box 1943 Hervey Bay QLD 4655
14 January 2010
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