Are you nominating yourself or someone else? *

Nominating myselfNominating another Burgmann Alumni or Staff Member

Nominee details if nomination someone else

Nominee Name Dr/Mx/Mr/Mrs/Ms/Miss or specify

Is this nominee aware you are nominating them? *

YesNo

Nomination Category *

Distinguished Alumni Award (35+ years)Outstanding Alumni Award (under 35 years)Burgmann Volunteer AwardStaff Award

Persuasive Statement

Please provide a 250-word persuasive statement outlining the achievements, impact and contribution of the nominee. Note: The nomination should address the criteria for selection. *

Please attached supporting documentation, such as a CV, certificates, articles, published papers, web & video links, etc to accompany the nomination.Upload your supporting documentation in a word or pdf document

Declaration and authority to use information

• I declare the information provided in this nomination form true and correct.

• I understand the information provided in this nomination will be used by Burgmann College in selecting award finalists and consent is provided for the use of such information for that purpose.

• I further consent to the use of such information for research, educational or any purposes, as long as such does not divulge my identity or the identity of the nominee to any person other than Burgmann College and their respective affiliates.

• I understand that my information will be handled in line with the Burgmann College Privacy Policy which is found on this website under Policies.

Alumni Award Nomination Form

Nominator Details

Nominee details if nomination someone else

Persuasive Statement