Online Form - Youth Awards Nomination Form » City of Kalgoorlie-Boulder

NOMINATION FOR (please tick)

Hit FM Kalgoorlie-Boulder Young Achiever.
Hit FM Kalgoorlie-Boulder Young Tradesperson/Apprentice.
Hit FM Kalgoorlie-Boulder Young Community Champion.
Hit FM Kalgoorlie-Boulder Young Cultural Leader.
Hit FM Kalgoorlie-Boulder Youth Organisation.
Hit FM Kalgoorlie-Boulder Youth Worker or Volunteer.

NOMINEE DETAILS (the person you are nominating):

Title *

Given Names *

Surname *

Address

Street Address:

Suburb/Town:

State:

Post Code:

Country:

Telephone (Home) (Work)

Mobile *

Email *

Does the nominee know they are being nominated? *

YesNo

Nominee Age *

REASONS FOR NOMINATION

REASONS FOR NOMINATION
Please refer to selection criteria for nominated award category. Include the nominee’s community involvement, educational or
employment achievements, the project or initiative being delivered and/or any other noteworthy achievements or community
contributions. Additional documents to support your nomination are encouraged.

REASONS FOR NOMINATION *

NOMINATOR

Title *

Given Names *

Surname *

Address

Street Address:

Suburb/Town:

State:

Post Code:

Country:

Telephone (Home) (Work)

Mobile *

Email *

Date you are making nomination *

OTHER PERSON WILLING TO SUPPORT YOUR NOMINATION

Title *

Given Names *

Surname *

Address

Street Address:

Suburb/Town:

State:

Post Code:

Country:

Telephone (Home) (Work)

Mobile *

Email *

PLEASE NOTE

A City officer may contact the nominee, nominator or nomination supporters to discuss this nomination.

TERMS, CONDITIONS & SELECTION CRITERIA APPLY

Terms and conditions and full selection criteria for the Hit FM Kalgoorlie-Boulder Youth Awards can be downloaded from
www.ckb.wa.gov.au/YouthAwards, or by contacting the City of Kalgoorlie-Boulder.

RETURN COMPLETED FORMS TO

City of Kalgoorlie-Boulder Healthy Communities Team:
City of Kalgoorlie-Boulder Administration Building, 577 Hannan Street, Kalgoorlie OR PO Box 2042, Boulder WA 6432
Telephone: (08) 9021 9600 Fax: (08) 9021 6113 Email: mailbag@ckb.wa.gov.au