NOMINATIONS CLOSE 12PM ON THURSDAY, 30 NOVEMBER 2017

NOMINEE’S DETAILS:Name:

Address: Postcode:

Phone (B): Phone (H):

Email:

NOMINATOR’S DETAILS: (person or organisation)

Name:

Address: Postcode:

Phone (B): Phone (H):

Email:

Please provide the name of at least one person who is familiar with the achievements of this nomination who can act as a referee. Nominators or referees may be asked to support their nomination by attending an informal discussion with the selection panel.

REFEREE’S DETAILS:#1 Name:

Address: Postcode:

Phone (B): Phone (H):

Email:

#2 Name:

Address: Postcode:

Phone (B): Phone (H):

Email:

Local Hero Nomination Form

Australia Day Awards 2018

Australia Day Awards 2018

For further information or assistance with compiling your submission, please contact Knox City Council by calling 9298 8000 or emailing knoxcc@knox.vic.gov.au

How to compile your nomination• Read the eligibility section on this form.• Attached submissions should be typed and around 500 words; maximum 1000 words.• Explain relevant achievements, background and reasons for your nomination.• Enclose clear copies of any newspaper or magazine articles about the nominee and relevant

achievements.• List any other awards.• Include any other relevant information.

What is a Local Hero?The intent of this award is to recognise people who have made a specific single contribution, or who have performed an heroic deed which may not fit the eligibility of the other Local Australia/Day Awards.

Conditions of entry• The name of at least one referee must be supplied.• The decision of the Knox City Council Local Australia Day Awards Committee is final and no

correspondence will be entered into in regard to that decision. • Entries should be delivered by hand or received in the mail by 12pm on Thursday,

30 November 2017. Council’s address is Knox Civic Centre, 511 Burwood Highway, Wantirna South, VIC, 3152.

Privacy StatementAll personal information collected is for the Australia Day Local Awards process and will be used solely by Council for that primary purpose or directly related purposes. Any named person on this application may apply to Council for access to and/or amendment of the information.