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  • DSR Awards 2016 Nomination Form – Lifetime Achievement

    Nominee Details

    First Name * :

    Last Name * :

    Address * :

    Suburb * :

    State * :

    Postcode * :

    Mobile * :

    Email * :

    Sport or recreation type * :

    Team Name (where applicable) :

    Organisation (where applicable) :

    Is the nominee aware of this nomination? *:

    Nominated by

    I am self nominating.

    First Name * :

    Last Name * :

    Address * :

    Suburb * :

    State * :

    Postcode * :

    Mobile * :

    Email * :

    Relationship to nominee (ie. Family member, colleague, coach, organisation) * :

    How did you find out about the awards?

    Please specify the other


    Questions - Lifetime Achievement Award


    1. Please provide an explanation as to why the nominee should be recognised for the Lifetime Achievement Award. Please include their impact on disability sport and/or recreation and number of years involved.
    Minimum 300 words, maximum 600 words

    2. Does the nominee identify as having a disability?

    Extra Information

    You may attach supporting evidence (no more than three A4 pages)(Allowed file types:gif|png|jpg|jpeg|pdf & file size max 2mb)

     

    Please upload one – two photos of the nominee.(Allowed file types:gif|png|jpg|jpeg & file size max 2mb)

    Photo 1:

    Photo 2:


    Who can we contact in support of this nomination?
    Please provide at least one reference.

    Referee details


    Referee One

    First Name * :

    Last Name * :

    Email * :

    Mobile * :

    Relationship to nominee (ie. Family member, colleague, coach, organisation) * :

    Referee Two

    First Name :

    Last Name :

    Email :

    Mobile :

    Relationship to nominee (ie. Family member, colleague, coach, organisation) :

    Before you submit your nomination, please print a copy for your records