City of Wanneroo

Instructions

For enquiries that are of an urgent-nature that require immediate assistance or that relate to animals, parking, ranger assistance or other community safety matters, please call us on (08) 9405 5000

To ensure a timely and professional response, please complete this form with as much detail as possible.

Your personal information collected in this form will help us to complete your request or to improve our services, in accordance with the City's Personal Information Privacy Policy.

Australia Day Award Nomination

There are four categories of awards to select from:

1. City of Wanneroo Australia Day Award - presented to an individual over 25 years of age who has made an outstanding contribution to the local community.

2. City of Wanneroo Charles Searson Australia Day Youth Award - presented to an individual less than 26 years of age who has made an outstanding contribution to the local community.

3. City of Wanneroo Australia Day Community Group or Event Award - presented to an outstanding local community group or event

4. City of Wanneroo Australia Day Senior Award - presented to an individual over 65 years of age who has made outstanding contributions and/or has made a longstanding commitment to the local community.

Please select award category (Required)

NOMINEE DETAILS

First and last name (Required)

Group or event name

Address (Required)

Phone number (Required)

Business phone

Email address (Required)

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REASON FOR NOMINATION

Reasons for nomination (How have their efforts made a positive impact on the local community? Has the nominee received any previous awards? If so, please give as much detail as possible) *

Please provide details

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YOUR DETAILS

Title (Required)

First name (Required)

Last name (Required)

Address. (Required)

Contact phone number (Required)

Email address. (Required)

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OTHERS SUPPORTING THE NOMINATION

Name 1

Contact number 1

Name 2

Contact number 2

Name 3

Contact number 3

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