MEDAL FOR SERVICE TO SOCIETY NOMINATION FORM

AWARD CRITERIA

When making your nomination, please provide short statements describing how the nominee meets the following award criteria. Where possible, provide examples to support the statements.

NOMINATION FORM

1. Demonstrated benefit to society at a local, regional, state, national or international level.* - required

2. Demonstrated achievements of the nominee and the work for which he/she is being nominated.* - required

3. Demonstrated qualities (attitude, support provided, initiative) in their role.* - required

4. Demonstrated evidence of innovation, initiative or obstacles which the nominee may have had to overcome to achieve their outcomes.* - required

NOMINEE DETAILS

SURNAME* - required

GIVEN NAME* - required

PREFERRED NAME* - required

ADDRESS (including postcode)* - required

PHONE NUMBER* - required

EMAIL ADDRESS* - required

NAME OF ORGANISATION(S) THE NOMINEE PROVIDES VOLUNTEER SERVICES FOR* - required

ANY ADDITIONAL INFORMATION YOU WOULD LIKE TO PROVIDE

NOMINATED BY

FULL NAME* - required

RELATIONSHIP TO GGS* - required

ADDRESS (including postcode)* - required

PHONE NUMBER* - required

EMAIL ADDRESS* - required

RELATIONSHIP TO NOMINEE* - required

NOMINEE REFERENCES (Others who may support this nomination)

NAME OF REFEREE 1

PHONE NUMBER

EMAIL ADDRESS

ADDRESS (including postcode)

NAME OF REFEREE 2

PHONE NUMBER

EMAIL ADDRESS

ADDRESS (including postcode)

NAME OF REFEREE 3

PHONE NUMBER

EMAIL ADDRESS

ADDRESS (including postcode)

Mandatory field(s) marked with *

MEDAL FOR SERVICE TO SOCIETY NOMINATION FORM

AWARD CRITERIA

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