Nominee Details

I/we nominate the following person for a Harmony Award:

Nominee Name:

Nominee Address:

Nominee Telephone Numbers:
Day:

Evening:

Nominee Occupation/Role:

Category

Please select one of the following:

  People and Well Being

  Art and Culture

  Sport

  Environment

  Education

  Enterprise

Reasons for Award

Please provide a factual statement of those services or activities for which it is considered the nominee merits recognition. The statement should include details of any relevant positions held and dates of service. If the services are voluntary this fact should be noted. If the nomination is successful, background information from this section may be used in association with the announcement of the Award granted.

Details of Person/Group Making Nomination

Please complete the following details so that you may be contacted if necessary.

My/Our Name:

My/Our Address:

My/Our Email Address:

Nominator's Telephone Numbers:
Day:

Evening:

Relationship to Nominee:

Name of Group:

Your Office:

Signature:

Date: