Online Form - Citizen of the Year Awards Nominations Form

Please provide as much information as possible. Additional documents may be attached providing further information of testimonials of achievement.

Award Category *

CITIZENSENIOR CITIZENYOUNG CITIZENCOMMUNITY EVENT

Nominee Full Name: *

Nominee Address

Street Address:

City:

State:

Post Code:

Country:

Nominee Phone *

Nominee Email *

Nominee Date of Birth *

Is the person being nominated an Australian citizen? *

YesNo

How has the person/organisation contributed to the community? *

Please list any other significant contributions and/or achievements? *

Any additional documents

Nominator Name *

Nominator Address

Street Address:

City:

State:

Post Code:

Country:

Nominator Phone *

Nominator Email *

I give permission for the Australia Day Council NT to submit this nomination to other recognition programs such as the Australian of the Year Awards *

yes