Ambassador Program Nomination Form

City of Newcastle acknowledges that we operate on the grounds of the traditional country of the Awabakal and Worimi peoples.
We recognise and respect their cultural heritage, beliefs and continuing relationship with the land, and that they are the proud survivors of more than two hundred years of dispossession.
CN reiterates its commitment to address disadvantages and attain justice for Aboriginal and Torres Strait Islander peoples of this community.

Details of person or community group being nominated
Title:
First Name:
Last Name:
Community Group:
Email:
Phone:
Mobile:
Address:
Suburb:
State:
Postcode:
More Information
Live and work:	Does the nominee currently live and /or work in The City of Newcastle?
Is the nominee an Australia citizen?:	Yes No Not sure
Is the nominee aware of the nomination:	Yes No Not sure
Two Referees
Name:
Position:
Relationship to Nominee:
Email:
Contact number:
Name:
Position:
Relationship to Nominee:
Email:
Contact number:
Selection Criteria
Contributions:	Describe how your nominee has contributed to the promotion of The City of Newcastle.
Commitment:	Describe how your nominee, if selected as an Ambassador, will continue to demonstrate a commitment to The City of Newcastle.
Excellence:	Describe how your nominee has demonstrated excellence in their field and how their work has impacted on The City of Newcastle.
Upload files
Upload file 1:	Upload copies of additional documents such as letters of commendation, awards the nominee has received, press articles and any other relevant information to support this nomination.
Upload file 2:
Upload file 3:
I Agree
Checklist:	I have read the nomination guidelines and critiera I have address all the selection criteria questions The information provided in this nomination is accurate Additional information (supporting material such as letters of commendation and press articles) have been attached
Declaration
Declaration by nominator:	I declare that the information about the nominee and his/her achievements or contribution contained in this nomination is to my knowledge true and accurate.
Title:
First Name:
Last Name:
Email:
Address:
Surburb:
Postcode:
Contact number:
Organisation (if relevant):
Security code:

Ambassador Program Nomination Form

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