Everald Compton Community Champion Medal Nomination Form Please fill in the form below to nominate a senior Australian for the Everald Compton Community Champion Medal. Nominee Details Question Title * 1. Full name Question Title * 2. Email Question Title * 3. Contact Number Question Title * 4. State ACT NSW QLD SA VIC NT WA Question Title * 5. Postcode Question Title * 6. Can you confirm the nominee is aged 50 or over? Yes No Question Title * 7. Please let us know in 300 words or less why you believe the nominee should be the recipient of the Everald Compton Community Champion Medal. Please provide 2 referees who can support the nomination and who would be willing to be contacted by NSA to verify the information supplied. Referee 1 Question Title * 8. Full name Question Title * 9. Email Question Title * 10. Contact Number Referee 2 Question Title * 11. Full name Question Title * 12. Email Question Title * 13. Contact Number Your details (nominator) Question Title * 14. Full name Question Title * 15. Email Question Title * 16. Contact Number Question Title * 17. Consent By submitting this form, I agree that National Seniors Australia may contact me about future campaigns and initiatives in line with their Terms of Service and Privacy Policy Shortlisted nominees will be required to have nominations verified. This will include reference checks and an Australian Federal Police check. Nominators will be contacted by NSA before this process begins. Entries close 15 August 2024 at 11.59pm AEST. Done