Nominator details

Given name *

Family name *

Organisation name *

Position title in organisation *

Phone number *

Email Address *

Organisation postal address (where certificates will be posted to) *

Street address *Street address line 2

City *

State *Please 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

Nomination

I am nominating *

one persona team

Nominee details

Given name *

Family name *

Residential suburb *

Organisation name - where the person volunteers *

Supporting statementPlease describe why the nominee deserves to be recognised and what qualities they have that sets them apart from other volunteers. Think about how they have gone above and beyond the call of duty and the impact they have had in their community (maximum 300 words/1500 characters).

Team details

Team name *

Organisation name - where the team volunteers *

Supporting statement *Please describe why the team deserves to be recognised and what qualities they have that sets them apart from other volunteers. Think about how they have gone above and beyond the call of duty and the impact they have had in their community (maximum 300 words/1500 characters).

Declaration

By submitting this form:

I confirm that, to the best of my knowledge and belief, the information in this form is true and correct.

*

I understand that the Department of Human Services may contact me to discuss the nomination and that information provided will be used to verify organisational and nominee eligibility. *

Recaptcha *

Privacy statement

The Department of Human Services (DHS) will use information collected from this form for the purpose of the Premier’s Certificate of Recognition for Outstanding Volunteer Service. In accordance with DHS’ Privacy Policy, DHS undertakes to treat any personal information provided by you as confidential and only for the purposes indicated above. Any information submitted will only be retained for such time as necessary to carry out the purposes for which the information is collected or as required by law. Email addresses and any other contact details you provide will not be provided to a third party or added to a mailing list without your consent.

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