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* 1. Nomination for:

Details of the person/team being nominated

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* 2. Name

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* 3. Phone

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* 4. Address

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* 5. Date of birth

Date

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* 6. Does the nominee currently live and/or work in Bogan Shire?

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* 7. Is the nominee an Australian Citizen?

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* 8. Will the nominee be aged 26 years or over on 26 January 2025?

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* 9. Has the nominee agreed to be nominated for this award?

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* 10. Contribution to the community for which the person is nominated. (Include membership or life membership of community and/or sporting groups, awards and other significant achievements.)

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* 11. Please attach additional supporting material, including references and media (newspaper clippings) if applicable.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File
Other persons to contact for further information about nominee

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* 12. Name

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* 13. Address

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* 14. Phone

Details about person submitting nomination

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* 15. Name

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* 16. Address

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* 17. Phone

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* 18. Please use this checklist to ensure that your nomination is complete.

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