Regional Leader of the Year Nominee Form

Please note: The below form is an online form and cannot be saved once you have started completing the questions.

Click here to download the nominee form

NOMINEE DETAILS

Nominee Name *

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Please upload a head and shoulders image of yourself. Image size of 1MB minimum. *

Click or drag a file to this area to upload.

NOMINEE QUESTIONS

Community involvement roles within the last 5-10 years. Please include: Organisation name, date/s you were involved, your role and responsibilities. Community Role 1: *

Community Role 2: *

Community Role 3: *

At what level are you involved in Dairy Women's Network *

How do you contribute to your local rural and dairying community? *

In what ways do you see yourself as a positive role model for Dairy Women's Network? *

Please provide us with two referees contact details that you have dealt with in the past two years. *

Acknowledgement

By ticking this box, you agree to the below Acknowledgement Statement.

1. I, [nominee name], warrant that I have never acted or behaved in a manner and will not during the period of the RL Award (as defined below) act or behave in a manner which, in the reasonable opinion of Dairy Women’s Network (DWN), is likely to detract from the reputation of DWN or any sponsors of the Dairy Women's Network Regional Leader of the Year award (RL Award), and/or causes or is likely to cause DWN or any sponsors of the RL Award to be brought into disrepute, contempt, scandal or ridicule, or otherwise cause or likely to cause public controversy or adversely affect the reputation of DWN or any sponsors of the RL Award or the value of the sponsorship relating to the RL Award to DWN. 2. I acknowledge that if I am the winner of the RL Award, any sponsorship benefits received or associated with the RL Award may be revoked or cancelled if DWN finds evidence that I have failed to act in accordance with clause 1 above.

Regional Leader of the Year Nominee Form

NOMINEE DETAILS

NOMINEE QUESTIONS

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