Nomination Form

It is important to complete the nomination form as fully as possible in order to assist the shortlisting process. All nominations will be judged on their own merit. If you need any help or advice filling in this form please contact:

All forms must be received by 1st October 2007 at 12pm – Late entries will not be accepted.

Please complete all fields

Category:

Details of the person you wish to nominate:

Age (if known):

Title:

Full Name:

Group Name (if applicable):

Address:

Nominee’s contact tel. number:

If under 18 please provide name, address and a contact number for a parent or guardian:

Parent/Guardian Name:

Parent/Guardian Address:

Parent/Guardian Telephone Number:

Your Details:

Your Name:

Your Address:

Do you wish to stay anonymous:

Please tell us why you feel this person or group deserves a recognition award for their work:

Active Citizen

Nomination Form