CITIZEN OF THE YEAR AWARD NOMINATION FORM 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 26 years of age or over as at 26 January 2010 DETAILS OF NOMINEE First Name: …………………………………………………….Surname: ……………………………………………… Home Address: ….............................................................................................. Home Telephone :(
) ............................ Mobile Telephone: .............................
Age…………. 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 ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................
PLEASE INDICATE ANY PAST OR PRESENT MEMBERSHIP OF COMMUNITY GROUPS ........................................................................................................................ ........................................................................................................................ ........................................................................................................................ ........................................................................................................................
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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