Online Form - Lifetime Contribution to Volunteering

This award will be presented in honour of a senior individual (65+ years) who has made an exemplary life-long contribution to volunteering and who, through their volunteering, has contributed to the betterment of the Town of Bassendean community.

About the person you are nominating:

Please tick the boxes below to show that your nomination meets all the following criteria:*

This person lives in the Town of Bassendean.
I am not the person being nominated.
I understand the assessment of the nominee will be made based on the information that I provide in this application.
I understand that a copy of this application will be shared with the Nominee.
I have read and agree with the Terms and Conditions.

Name (One Person only)*

Address*

Phone Number*

Email Address*

Has the nominee's contribution been recognised elsewhere?

Reason for nomination:

In this section, please describe clearly and to the point what the nominee has done and why you think they should be recognised. Tell us what you know and what you think is noteworthy about your nominee’s service and achievements.

How, through their volunteering, has this person: made an exemplary life-long contribution and contributed to the betterment of the Town of Bassendean community?*

Please provide your details:

Your Name*

Address

Street Address:*

City:*

State:*

Post Code:*

Country:*

Email Address*

Phone Number*

Where did you hear about these awards?*

Terms & Conditions

Thank you for taking the time to complete your nomination.

Please accept the Terms and Conditions to continue:

Acceptance*

I have read and agree to the Terms and Conditions in the link above

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