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CRANBOURNE CHAMBER OF COMMERCE
COMMUNITY AWARD 2015
Nomination Form
Nominee Details
Nominee First Name:
Nominee Last Name:
Residential Address:
Daytime Phone Number:
Occupation:
Employer:
Email Address:
Work Status:
Full Time
Part Time
Retired/Other
Benefits to the Cranbourne Community
The nomination is assessed and compared to other nominations using this information. Please include as much detail as possible.
Please tell us about this nominee and why you believe they would be a worthy winner of the Community Award 2015:
Please describe how their contributions have benefitted the Cranbourne Community and had a positive impact on the
lives of residents and/or local organisations.
Nominator’s Details
These are the contact details of the person who is submitting this form
First Name:
Last Name:
Postal Address:
Daytime Phone Number:
Email Address:
Relationship to Nominee:
Nominator Declaration
I declare that the information I have provided in this nomination is true and correct and I can attest to the contribution
made by the nominee to the Cranbourne community and to the details provided in this nomination. I declare that the
nominee is aware of the nomination and agrees to the terms and conditions of this award.
Nominator’s Signature
Date
Independent Referee’s Details
These are the contact details of the Independent Referee.
First Name:
Last Name:
Postal Address:
Daytime Phone Number:
Email Address:
Relationship to Nominee:
Both Nominator and Independent Referee must be prepared to be contacted to clarify Nominee details
On behalf of the Cranbourne Chamber of Commerce we thank you for presenting this nominee for consideration by the
Community Award 2015 Selection Panel. All decisions approved by the Chamber are final.
If your nomination is complete and you are ready to SUBMIT, please scan and email to [email protected]
with the subject ‘Community Award, [nominee’s name]’
OR post through to PO Box 221 Cranbourne VIC 3977; by 5pm Wednesday 15 July 2015.
Once submitted, you will receive an email to confirm that the form has been successfully submitted. This will be sent to the email
address the Nominator used to register.
Please contact the Cranbourne Chamber of Commerce committee on 0411 295 312 if you do not receive a confirmation email,
as it may mean that your nomination has not been received.