Deakin University Alumni Awards Nomination form 2015
PURPOSE of the AWARDS Deakin University’s annual Alumni of the Year Awards recognise, acknowledge and promote prominent and successful Deakin Alumni, who have made outstanding contributions to their communities, professions and/or towards the advancement of Deakin University’s strategic endeavours. SUBMISSION OF NOMINATION All completed nominations must be attached and emailed to [email protected] .Your nomination must be submitted to the Deakin University Alumni Relations Office by 5pm (AEST) Monday 1 June 2015. Nominations will only be accepted by via email using the prescribed nomination form. STEP 1 OF 7 NOMINEE DETAILS (*please complete all fields)
TITLE (Dr, Mr, Ms etc.)
NOMINEES FULL NAME
SUFFIX (OAM, AM)
STUDENT ID DATE OF BIRTH (dd/mm/yyyy)
TELEPHONE NUMBER
MOBILE PHONE NUMBER
POSTAL ADDRESS
EMAIL ADDRESS CURRENT OCCUPATION (if retired please provide last occupation held)
CURRENT EMPLOYER
Deakin University CRICOS Provider Code: 00113B
Alumni Relations Office Melbourne Burwood Campus, 221 Burwood Highway, Burwood, VIC 3125
Tel 03 5227 1019 [email protected] www.deakin.edu.au/alumni
Deakin University Alumni Awards Nomination form 2015
DEAKIN/ANTECEDENT INSTITUTION QUALIFICATIONS (if applicable)
NAME OF DEGREE YEAR OF GRADUATION
INSTITUTION
DEGREE 1 DEGREE 2 DEGREE 3
STEP 2 OF 7 NOMINATOR DETAILS (*please complete all fields)
TITLE (Dr, Mr, Ms etc.)
FULL NAME
SUFFIX (OAM, AM) RELATIONSHIP TO NOMINEE
TELEPHONE NUMBER
MOBILE PHONE NUMBER PREFERRED POSTAL ADDRESS
PREFERRED EMAIL ADDRESS
CURRENT OCCUPATION (if retired please provide last occupation held)
CURRENT EMPLOYER
Deakin University CRICOS Provider Code: 00113B
Alumni Relations Office Melbourne Burwood Campus, 221 Burwood Highway, Burwood, VIC 3125
Tel 03 5227 1019 [email protected] www.deakin.edu.au/alumni
Deakin University Alumni Awards Nomination form 2015
STEP 3 of 7 AWARD CATEGORIES (select applicable award for consideration) Lifetime Achievement Award
Open to any Deakin graduates, who over the course of their lifetime have built an outstanding reputation and have demonstrated both exceptional and prolonged achievement in their professional and/or community endeavours. Alumni of the Year Award
Open to any Deakin Alumni member aged 40 years or over (at the time of nomination) that has consistently demonstrated outstanding success in their professional and/or community endeavours. Young Alumni of the Year Award
Open to any Deakin Alumni member aged under 40 years of age (at the time of nomination) that has demonstrated outstanding success in their professional endeavours, and/or community endeavours.
Alumni Community Service Award
Open to any Deakin Alumni member and recognises the work of an outstanding individual who has consistently demonstrated:
• Outstanding volunteer leadership and service to Deakin University, enhancing the affiliations between Deakin’s alumni, students and the broader community and thereby helping to drive core university goals; and/or
• Significant voluntary contributions which have led to enduring positive outcomes for the wellbeing of others within their community
Deakin University CRICOS Provider Code: 00113B
Alumni Relations Office Melbourne Burwood Campus, 221 Burwood Highway, Burwood, VIC 3125
Tel 03 5227 1019 [email protected] www.deakin.edu.au/alumni
Deakin University Alumni Awards Nomination form 2015
STEP 4 OF 7 SUPPORTING STATEMENT AND RESUME/BIOGRAPHY In less than 500 words state why as nominator, this person should be considered for the award, ensuring you address how this person meets the selection criteria for the specific award. This précis should include a detailed chronological list of positions held and achievements.
Note any additional wording over 500 will not be considered.
Deakin University CRICOS Provider Code: 00113B
Alumni Relations Office Melbourne Burwood Campus, 221 Burwood Highway, Burwood, VIC 3125
Tel 03 5227 1019 [email protected] www.deakin.edu.au/alumni
Deakin University Alumni Awards Nomination form 2015
STEP 5 OF 7 NOMINEE’S REFEREES (*please provide the details of two referees)
REFEREE 1
FULL NAME
RELATIONSHIP TO NOMINEE PREFERRED TELEPHONE NUMBER
PREFERRED EMAIL ADDRESS CURRENT OCCUPATION (if retired please provide last occupation held)
CURRENT EMPLOYER
REFEREE 2
FULL NAME
RELATIONSHIP TO NOMINEE PREFERRED TELEPHONE NUMBER
PREFERRED EMAIL ADDRESS CURRENT OCCUPATION (if retired please provide last occupation held)
CURRENT EMPLOYER
Deakin University CRICOS Provider Code: 00113B
Alumni Relations Office Melbourne Burwood Campus, 221 Burwood Highway, Burwood, VIC 3125
Tel 03 5227 1019 [email protected] www.deakin.edu.au/alumni
Deakin University Alumni Awards Nomination form 2015
STEP 6 OF 7 OTHER SUPPORTING EVIDENCE (optional) You may wish to include any other important information you think relevant to support this nomination. This may take the form of links to: media articles, electronic media, websites etc. (up to a maximum 3 items of supporting evidence) ☐ I have supplied a link with additional information in support of this nomination OR ☐ I do not wish to supply any other supporting evidence STEP 7 OF 7 NOMINATION CHECKLIST, CONFIRMATION AND SUBMISSION CHECKLIST Please check each box in the checklist below to ensure you have included all necessary information and supporting documents. I have included in this nomination (please check): ☐ A fully completed nomination form ☐ A statement supporting the nomination, addressing the selection criteria ☐ Contact details for two referees ☐ Other supporting documentation (if applicable) CONFIRMATION ☐ I acknowledge that submitting this nomination form does not imply in any way that the nominee will be selected to receive an award. ☐ I understand that this nomination and all supporting documentation are confidential
Deakin University CRICOS Provider Code: 00113B
Alumni Relations Office Melbourne Burwood Campus, 221 Burwood Highway, Burwood, VIC 3125
Tel 03 5227 1019 [email protected] www.deakin.edu.au/alumni
Deakin University Alumni Awards Nomination form 2015
SUBMISSION OF NOMINATION All completed nominations must be attached and emailed to [email protected] .Your nomination must be submitted to the Deakin University Alumni Relations Office by 5pm (AEST) Monday 1 June 2015. Nominations will only be accepted by via email using the prescribed nomination form.
Deakin University CRICOS Provider Code: 00113B
Alumni Relations Office Melbourne Burwood Campus, 221 Burwood Highway, Burwood, VIC 3125
Tel 03 5227 1019 [email protected] www.deakin.edu.au/alumni