Please fill in the form below to nominate a senior Australian for the Everald Compton Community Champion Medal.
Nominee Details

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* 1. Full name

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* 2. Email

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* 3. Contact Number

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* 4. State

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* 5. Postcode

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* 6. Can you confirm the nominee is aged 50 or over?

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* 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

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* 8. Full name

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* 9. Email

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* 10. Contact Number

Referee 2

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* 11. Full name

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* 12. Email

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* 13. Contact Number

Your details (nominator)

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* 14. Full name

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* 15. Email

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* 16. Contact Number

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* 17.
Consent

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.

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