2015 PREMIER’S MULTICULTURAL COMMUNITY MEDALS
MULTICULTURAL HONOUR ROLL
NOMINATION FORM FOR SERVICE TO THE COMMUNITY
Tick only one category. Use another form if you have more than one nomination
IS YOUR NOMINATION FOR:
PREMIER’S MULTICULTURAL COMMUNITY MEDAL (complete sections 1 and 2)
or
MULTICULTURAL HONOUR ROLL (complete sections 1 and 3)
SECTION 1:
INFORMATION
ABOUT THE
NOMINATOR
AND NOMINEE
Name of organisation submitting the nomination
(leave blank if you are not from an organisation)
Your position in the organisation
(leave blank if you are not from an organisation)
SECTION 2:
NOMINATION
FORM FOR
2015 PREMIER’S
MULTICULTURAL
COMMUNITY
MEDAL
NOMINATIONS FOR THE MEDAL
MUST BE SUPPORTED BY:
Name of nominator
Address
Complete this section together with details of two referees who support this
nomination.
Nominations must include evidence of exemplary service to the community with
identifiable, tangible and broadly recognised outcomes.
#
At least one high-profile community organisation and an eminent member of the community.
(These expressions of support should be signed and submitted individually and those by an organisation are to be on that organisation’s letterhead)
This expressions of support, should include, but not be limited to, the following:
Telephone number
Email
#
Extent to which the nominee’s contribution is noteworthy
#
Length and level of contribution and service
#
Explain why the nominee’s work is considered to be above and beyond the call of duty
Name of nominee
#
In what way is the nominee’s contribution recognised by his/her or the wider NSW community.
Address of nominee
Telephone number of nominee
Email of nominee
UNDER WHICH CATEGORY DO
YOU WISH TO NOMINATE YOUR
NOMINEE?
Stepan Kerkyasharian AO Harmony Award
Youth (25 years of age or under)
Lifetime Community Service
Arts and Culture
Regional Communities
Economic Participation
EVIDENCE
Detail the timeframe, length and level of the nominee’s contribution
Describe in detail the community contribution undertaken by the nominee as it relates to the category under which you are
nominating that person. Attach an additional page if required
Explain how the nominee’s contribution is noteworthy
Describe any lasting or meaningful contribution the nominee’s community service
has made
Describe any acknowledgement or recognition of the nominee’s contribution by the wider community
The Multicultural Honour Roll is a posthumous permanent public record of the
SECTION 3 significant and exemplary contribution made by the people of our multicultural
society.
NOMINATION
Complete this section together with details of two referees who support this
nomination.
FORM FOR
MULTICULTURAL Name of nominee
Date and place of birth
HONOUR ROLL
Date of passing away
Describe in detail how the nominee made a significant, lasting and exemplary contribution to a community in New South Wales.
Provide any other supporting information. If more space is required, an additional page or other information you consider
relevant to this nomination may be attached.
Attach an additional page if required
Referees (two) who support a nomination for the Premier’s Multicultural Community Medals
Referees (two) who support a nomination for the Multicultural Honour Roll
Name
Name
Name
Name
Telephone
Telephone
Telephone
Telephone
Email
Email
Email
Email
In what capacity does this referee know the nominee?
In what capacity does this referee know the nominee?
In what capacity does this referee know the nominee?
In what capacity does this referee know the nominee?
NOMINATION PROCESS
1.
Please read the Nomination Categories and Eligibility Criteria and select the appropriate nomination category.
2.
If more space is required, you may attach additional pages.
3.
Copies of supporting material such as photographs or documents may be attached to the application. Please supply copies only, as originals will not be returned.
4.
Forms and supporting documentation should be returned to Multicultural NSW by 5:00pm, Friday 6 February 2015.
5.
Nomination forms can be sent as :
Email :
[email protected]
Post:
The Premier’s Multicultural Community Medals and Multicultural Honour Roll,
Multicultural NSW PO Box A2618 Sydney South NSW 1235
Hand delivered:
Level 8, 175 Castlereagh Street, Sydney
Enquiries:
02 8255 6767