Online Form - Clem Kentish Community Service Award - Nomination Form

The Clem Kentish Community Service Award aims to recognise long standing contributors to the Shire of Serpentine Jarrahdale community. In order to be considered for this prestigious award, the person being nominated must demonstrate the following:

Guidelines for the Award

Minimum length of service to the community is to have been at least twenty (20) years.
Nominee is to have served on several committees that have benefited the community.
Nominee is to be a resident of the Shire of Serpentine Jarrahdale.
Either organisations or individuals may make nominations for the award.
Winner is to be presented with a lapel badge and plaque at the Shire of Serpentine Jarrahdale’s Australia Day Awards’ Ceremony.

Completed forms must be submitted by Thursday, 31 October 2024.

Details of the person being nominated (Confidential)

Title*

Given names*

Surname*

Address*

Phone number*

Email*

Has the person contributed at least 20 years of service to the community?*

Yes

Please outline the main reasons for the nomination. Include the contributions the person has made to the community, as well as their involvement with community groups. Please reference years/dates wherever possible.*

What other contributions or achievements makes the person worthy of recognition?

Please outline all past and present memberships of community / sporting / professional bodies etc. Please include years/dates as relevant.

Please provide any other relevant background details: (NB. Additional information may be attached if desired)

Other persons who may be contacted for further information about nominee

Person 1

Name

Position

Address

Phone number

Person 2

Name

Position

Address

Phone number

To be completed by the person submitting the nomination

Name*

Address*

Phone number*

Email*

Organisation represented (if applicable)

Relationship to nominee*

Would you like to remain anonymous to the person you are submitting as a nominee?*

YesNo