2012 ACT Sportstar of the Year - Monthly Nomination Form

Nominee Details

Name

Address

Phone Number (W)

Phone Number (H)

Mobile Number

Fax Number

Email Address

Date of Birth

Sport

Nomination Category

Note: Full nominee contact details must be provided or nomination will not be accepted.

Nominee's contact details may be given to the media for publicity purposes. Please tick the box if you do not wish these details to be passed on.

Achievement Occurred During

Details of Sporting Achievement for the Month Nomination
NB: Please provide all relevant information including competition level, name of the event, national or international field etc. Any additional information provided may assist the nomination when judged.

Nominator Details

Name

Sporting Body/Association

Position Held in Sporting Body/Association

Business Address

Phone Number (W)

Phone Number (H)

Mobile Number

Email Address

Date of Nomination

2013 Lord’s Taverners Scholarship Scheme

The Tradies ACT Sportstar of the Year Awards

2013 ActewAGL ACT Sports Hall of Fame

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