Australian of the Year 2010 Nomination form

Nominations for the Australian of the Year Awards 2009 are now closed. Your nomination will be added to the nominations for the Australian of the Year Awards 2010.

Nominee

* means mandatory field.

Nominate an Australian Citizen for one or more of the four categories *
Australian of the Year Senior Australian of the Year (60 years and over) Young Australian of the Year (16 - 30 years) Australia's Local Hero
Title (Mr, Mrs, Ms, etc.) of your nominee *	Select title Mr Mrs Ms Miss Dr Prof Hon Father Rev Sister
First Name *
Surname *
Position/Organisation
Address
Suburb
State*	Select state ACT NSW NT QLD SA TAS VIC WA Unknown
Postcode
Telephone (H)
Telephone (W)
Mobile
Email
Age
Please select Exact Estimate Unknown

---

Area of Excellence *

In what area(s) has the nominee excelled? Please tick the relevant boxes below:

Arts, Media, Entertainment Business Charity Community Education Environment Humanitarian Indigenous/Ethnic Services Medicine/Science Technology/Engineering Sport Other

---

Tell us about your nominee. How are they an inspirational role model? How have they demonstrated excellence in their field and to the community?

---

Nominator

Your Title *	Select title Mr Mrs Ms Miss Dr Prof Hon
First Name *
Surname *
Position/Organisation (optional)
Address
Suburb
State *	Select state ACT NSW NT QLD SA TAS VIC WA
Postcode *
Telephone (H)
Telephone (W)
Mobile
Email
Age	Please select 8 - 25 26 - 45 46 - 75 76 +
Where did you obtain this nomination form from? *	Please select Commonwealth Bank Branch Commonwealth Bank Statement Holiday Inn QANTAS Club From a friend Internet Addressed mail Unaddressed mail Other
I am happy for my nominee to know that I nominated them.	Please select Yes No
I wish to have my email included in the Australian of the Year Awards Newsletter distribution list.	Please select Yes No

---

Referee (optional - may be contacted for further information)

Title	Select title Mr Mrs Ms Miss Dr Prof Hon
Referee's First Name
Surname
Position/Organisation (optional)
Address
Suburb
State	Select state ACT NSW NT QLD SA TAS VIC WA
Postcode
Telephone (H)
Telephone (W)
Mobile
Email

---

Relevant Documents / Files

File 1
File 2
File 3
File 4
File 5

---

Please do not nominate the same person more than once. Recipients are selected based on selection criteria, rather than the number of times they are nominated. Thank you.

We encourage you to include supporting documentation with your nomination. This can include, for example, personal references, portfolios, photographs, or samples of work. Please note that all documentation will be retained by the National Australia Day Council. Please send to:

National Australia Day Council
Old Parliament House
King George Terrace
Parkes ACT 2600

or e-mail to awardsinfo@australiaday.org.au. Please quote your receipt number on all materials.