Community Service Award Nomination Form

Nominations to the 2025 Community Service Awards are open until 5pm on Monday 30 June.

Before lodging a nomination, we recommend reading the Community Service Awards Guidelines.

A printable copy of the nomination form is available here.

For more information, please contact the Economic and Community Development team on community.development@belmont.wa.gov.au or 9477 7219.

Type of Nomination*

Nomination Category*

Select all that apply.

Details of the individual or community group being nominated

Nominee's Name*

Nominee's Address*

Nominee's Suburb*

Nominee's State*

Nominee's Postcode*

Nominee's Phone*

Nominator's Details

Nominator's Name*

Nominator's Address*

Nominator's Suburb*

Nominator's State*

Nominator's Postcode*

Nominator's Phone*

Relation to nominee*

Summary of achievement

Please provide details of the nominee's contribution, including the organisation(s) they volunteer for, their role, the number of years they have been volunteering in their role(s).

Name of organisation or group*

Volunteer role*

Number of years volunteering*

Please provide a summary of the nominee's voluntary tasks and achievements, including how their contribution aligns with the City's values, and significant highlights or events during the nominee's service. Refer to the selection criteria in the Community Service Awards 2024 Guidelines for the City's values.*

Number of peole reached and level of impact because of the nominee's contribution*

On the scale of 1 to 5, please rate the impact the nominee has had on individuals*

On the scale of 1 to 5, please rate the impact the nominee has had on the wider community*

Please provide summary/evidence to support your chosen number and level of impact*

Here is space to include any additional information highlighting or showcasing the nominee's positive impact on the Belmont community (optional)

Upload supporting evidence (optional)