EmailMe Form - Netball WA Service to Sport Nomination

Year of Nomination *

Please select your Association *

Title and Name of Nominator *

Nominator's Email *

Nominator's Phone Number *

### - ### - ####

Is the Nominator a Member of Netball WA? *

Yes

No

Details of Nominee

Full name of Nominee *

Address of Nominee *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Nominee's Email *

Nominee's Phone Number *

### - ### - ####

Is the Nominee a Member of Netball WA? *

Yes

No

Not sure

Life Membership of a Region (Name of Award, Year of Receiving)

Any other Awards relating to Netball

Contribution to Netball WA. *

Outline why this nominee should be considered for a Service Award. Your response must include detailed reasons for, and examples of, the nominee’s service and contributions. This information must explain how the nominated individual has made a significant, sustained and lasting contribution to Netball in WA.

Supporting Documentation *

Please list and attach any supporting documentation e.g., Nominee's Biography, newspaper articles/clippings, awards and certificates. Please note that all Nominations and all supporting documentation once submitted will become the property of Netball WA and will not be returned to the nominator.

Please attach supporting documentation *

Please attach a photo of the nominee *

Date Time *

MM / DD / YYYY

Checkbox *

The information provided in this Nomination Form is to my knowledge a true and accurate record and ticking this box is taken as my signature.