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
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