Nomination Form

NOMINATION FORM

PLEASE NOTE THAT THIS FORM MUST NOT BE REVEALED TO THE NOMINEE AS ALL NOMINATIONS ARE KEPT CONFIDENTIAL UNTIL THE FINALISTS HAVE BEEN IDENTIFIED

INSTRUCTIONS TO COMPLETE THE FORM BELOW

1. Please complete all sections below, adding space as necessary.

2. NOTE: Section 4 is the key section that supports your nomination.

3.For ease of description, the term ‘Emergency Service’ below includes Police.

4. If in doubt, contact the SESCA Ambassador (Pete Taylor) on mobile 0429 485 045 – for answers to your questions.

5. When complete, please submit your nomination via:

A. The "submit nomination" button below (preferred method); OR

B. If you are unable to do the online nomination, please email – contact@sesca.org.au; or phone Pete mobile 0429 485 045 to receive an emailed "Word" version; and

C. Then send your nomination via email to contact@sesca.org.au OR print the form and mail to – SESCA Nomination, Rotary Nowra, PO Box 226, NOWRA NSW 2541

D. Note that nominations close at 5pm, Tuesday, 9 June 2020

Submit Nomination

SESCA NOMINATION FORM

Section1: Nominee Details

Nominee's Title & Name:

Emergency Service Agency:

Email:

Phone:

Section 2 - Nominee's Current Role within ESA

2.1 Role / Job Title

2.2 How long have they been an ESA member?

2.3 Paid or Volunteer Member OR for Police: ‘Sworn Police’ or ‘Unsworn Police Employee’?

2.4 What other roles has the member held in the ESA?

Unit:

Street Address

Postal Address

4.1 WHAT are the normal duties of the nominee and what have they done in the course that demonstrates “Service Above Self” as an Emergency Service member?

4.2 WHAT has the nominee done in the Community, as additional service, that would demonstrate “Service Above Self” (eg is/was the nominee in scouts, Rotary, school committee and what did he/she do, etc, etc, etc?)

4.3 Is/was nominee a member of another Emergency Service Agency? And if so, what have they done in that service?

Name

Phone:

Relationship with Nominee:

Referee1 - Name

Phone

Relationship with nominee:

Referee 2 - Name

Phone

Relationship with nominee:

Thanks for submitting!