Part 1 - Nominee

All information entered in part 1 relates to the individual you are nominating for the SA Women of Impact Award.

I confirm that the elibility requirements have been met. *

I confirm that the selection criteria have been met. *

The nominee understands that if they are a finalist or winner of an award category they consent to having their biography and photograph displayed on the Office for Women website.
*

I confirm the nominee is over 18 years of age. *

Given Name *

Family Name *

Preferred name

Address

Street addressStreet address line 2

City

StatePlease selectACTNSWNTQLDSATASVICWA

Postcode

CountryPlease selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Phone

Email Address *

Occupation

Does the nominee identify as the following

AboriginalTorres Strait IslanderBoth Aboriginal and Torres Strait IslanderCulturally or linguistically diverseNone of the above

Is this a posthumous award?

NoYes

Nominee Resume *

Browse

Max. file size 3MB. Allowed file types .docx, .pdf.

Nominee photo *

Browse

Max. file size 5MB. Allowed file types .jpg, .jpeg, .png.

Which award category are you nominating the nominee for?  

See the Award catergories and descriptions above for more information.

Award category *

Impact in Industry AwardImpact in the Community AwardAboriginal Impact AwardImpact on ending Domestic, Family and Sexual Violence

About the nominee  

Please tell us why the nominee deserves to be nominated. The below questions have been set out toalign with the section criteria. Please provide details but limit responses to 200 words.

How is the nominee actively involved in the South Australian community?Maximum 1,000 characters

What is the nature and length of the nominee's involvement or action in their chosen field or endeavour?Maximum 1,000 characters

Please describe the nominee’s contribution to the community, field of work or endeavor and the lasting effects of their contributions including recognition as a leader or role model in the community.Maximum 1,000 characters

Please describe how the nominee possesses inspirational and leadership qualities and how they show innovation and creativity.Maximum 1,000 characters

How does the nominee actively promote the advancement of women’s rights and social justice as well as a special commitment to equity and diversity?Maximum 1,000 characters

Nominee Biography  

Up to 150 words. This information will be displayed on the Office for Women website.

 Maximum 1,000 characters

Part 2 - Nominated by

All information entered in part 2 relates to the individual submitting the nomination.

Given name *

Family name *

Phone

Email address *

How do you know the individual you are nominating? *

Part 3 - Referees

Referees may be contacted for further information if a nominee is shortlisted. Please provide the details of at least one member of the community who know the nominee personally and/or professionally and can comment on their achievements and their impact.

Referee 1

Given name *

Family name *

Phone

Email address *

Occupation

What can the referee comment on? *

Referee 2 (optional)

Given name

Family name

Phone

Email address

Occupation

What can the referee comment on?

I confirm the referees know I have provided their details to the Office for Women for the purpose of supporting this nomination. *

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