| Geelong Grammar School

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 support this nomination)

REFEREE 1

FULL NAME

PHONE NUMBER

EMAIL ADDRESS

ADDRESS (including postcode)

REFEREE 2

FULL NAME

PHONE NUMBER

EMAIL ADDRESS

ADDRESS (including postcode)

REFEREE 3

FULL NAME

PHONE NUMBER

EMAIL ADDRESS

ADDRESS (including postcode)