Community Leaders Award Nomination Form

Nominee Details

Name*

Address*

Street Address 1 Street Address 2 City State Post code

Phone*

Email*

Is the deadly person you are nominating Aboriginal and/or Torres Straight Islander living in Victoria?*

Where does the nominee work?*

Please provide a brief bio of the nominee*

This will be used on social media and websites if the nominee is successful in becoming a finalist and winner.

Name*

Phone*

Email*

A confirmation email will be automatically sent to this email address once the nomination has been submitted.

Organisation*

Are you nominating on behalf of an organisation? Have you received approval to do so?*

Relationship to the nominee*

Name

Phone

Email

Organisation

Relationship to the nominee

Statement of support for the nominee to be awarded the Mollie Dyer Award for the Community Award

Where does the nominee work?*

How has the nominee shown leadership, advocacy, inspired positive change and worked to strengthen Aboriginal children and families?*

500 characters max or 2 minute video Response can be written or submitted via video

Video response

If you are having difficulties uploading your video just contact us at awards@vacca.org