Order of Liverpool Awards 2022 Nomination Form

Before submitting a nomination form please read the Liverpool City Council Order of Liverpool 2022 Guidelines.

Nomination forms and associated information must be received by Friday 24 June 2022.

Completed nomination forms can also be sent to:

Council and Executive Services
Locked Bag 7064
Liverpool BC NSW 1871
or emailed to awards@liverpool.nsw.gov.au

Title:

Surname: *

Other Names: *

Address: *

Phone (W):

Phone (H):

Phone (M):

Date of Birth: *

Email *

Details of the nominee’s voluntary community service and duration of service (include membership of organisations and positions held, etc.): *

Details of the nominee’s involvement and contribution to the Liverpool community: *

Describe the nominee’s achievements *

Reasons for nominating this person: *

Applicants may include up to two copies of any other relevant information (such as certificates, awards, photos, newspaper clippings, etc.).

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Title: *

Surname: *

Other Names: *

Address: *

Phone (W):

Phone (H):

Phone (M):

Email: *

Title:

Surname: *

Other Names: *

Address: *

Phone (W):

Phone (H):

Phone (W):

Email: *