YORKE PENINSULA COUNCIL

SF 072 Nomination Form Australia Day Awards

Nominee (the person/organisation you would like to nominate) Please provide as much information as possible – leave blank any questions that don’t apply

Please list any other significant contributions and/or achievements: If not Australia, is the person being nominated an Australian citizen? Country of Birth: Date of Birth: Telephone Business: Telephone Private: Address: Community Event Citizen of the Year Young Citizen (<25) Position/Organisation (optional): Name: Award Category:

Reason for nomination – how has the person/organisation contributed to the community?

Additional material may be attached – maximum five A4 pages, minimum font size 10 point. Nominator (your details)

Date: Signature: Telephone Business: Telephone Private: Address: Name:

Please return your completed form prior to Friday 18th November 2016, marked as follows: Confidential Australia Day Awards Yorke Peninsula Council PO Box 57 MAITLAND SA 5573 Further information contact Jackie Reddaway Ph:88320000 or jackie.reddaway@yorke.sa.gov.au