Fellow Membership Nomination Award

DETAILS OF FELLOW BEING NOMINATED

Title: *

First Name: *

Family Name: *

Position: *

Name of Institution: *

Postal Address: *

City / Suburb: *

State: *

Country: *

Postcode: *

Contact Number (Business):

Contact Mobile:

Contact Email: *

Gender:

UndisclosedMaleFemale

AFAANZ Membership Number: *

Period and number of years of AFAANZ Membership:

SELECTION CRITERIA

I believe I have met the selection criteria as per the call for applications and have addressed same. (Self nomination):

Yes

or

believe the person I have nominated meets the selection criteria as per the call for applications and have addressed same. (Non-self nomination):

Yes

DETAILS OF NOMINATOR (if non-self nomination)

Title: *

First Name: *

Family Name: *

Position: *

Name of Institution:

Postal Address: *

City / Suburb: *

State: *

Country: *

Postcode: *

Contact Number (Business):

Contact Mobile:

Contact Email: *

AFAANZ Membership Number: *

SELF NOMINATOR’S CHECK LIST

Completed application form:

Yes

No

A one page statement that addresses the selection criteria:

Yes

No

If self nominating, two character references or testimonials from people familiar with your AFAANZ contribution and who can help attest to your community standing and contribution to AFAANZ (at least one of whom must be a member of AFAANZ):

Yes

No

If nominating another member, one character reference or testimonial from the nominating member, and one character reference or testimonial from a person familiar with the nominated person’s AFAANZ contribution who can help attest to their community stan:

Yes

No

The application form signed by the nominee and if applicable, the nominating member:

Yes

No

Any other information in support of the application (limited to no more than two pages):

Yes

No

DECLARATION

Self nomination

HEREBY DECLARE THAT the information provided in this application is true and correct. I understand that I must wait at least two years from the closing date of an application before reapplying if my application is unsuccessful.: *

Yes

or

Non-self nomination

I HEREBY DECLARE THAT the information provided in this application is true and correct. I also confirm the nominee agrees to be nominated for this award and understands that unsuccessful nominees must wait at least two years from the closing date of an ap: *

Yes

Nominee's Full Name:

Nominator's Full Name: