2026 Citizen of the Year - Nomination Form

Name of Nominee*

Address of Nominee

Street Address:

City:

State:

Post Code:

Country:

Contact Number of Nominee*

Nominated by*

Organisation Name

Nominator Email*

Nominator Phone Number*

Often after the event, recipients request to know who nominated them. Do you consent to your name being disclosed?*

YesNo

In 25 words, please summarise your nomination; highlighting the achievements and impacts made. This summary will be used for the nominee booklet and Australia Day Awards presentation*

How has the Nominee made an outstanding contribution to the local community?*

What are the most notable achievements of the nominee through their contributions to the community?*

How is the nominee an inspirational role model for the community?*

Welcome to the Shire of Dowerin

2026 Citizen of the Year Award

Nomination Form