Deakin University Alumni Awards Nomination form 2015 · 2015-04-30 · Deakin University Alumni...

Deakin University Alumni Awards Nomination form 2015

PURPOSE of the AWARDS Deakin University’s annual Alumni of the Year Awards recognise, acknowledge and promote prominent and successful Deakin Alumni, who have made outstanding contributions to their communities, professions and/or towards the advancement of Deakin University’s strategic endeavours. SUBMISSION OF NOMINATION All completed nominations must be attached and emailed to [email protected] .Your nomination must be submitted to the Deakin University Alumni Relations Office by 5pm (AEST) Monday 1 June 2015. Nominations will only be accepted by via email using the prescribed nomination form. STEP 1 OF 7 NOMINEE DETAILS (*please complete all fields)

TITLE (Dr, Mr, Ms etc.)

NOMINEES FULL NAME

SUFFIX (OAM, AM)

STUDENT ID DATE OF BIRTH (dd/mm/yyyy)

TELEPHONE NUMBER

MOBILE PHONE NUMBER

POSTAL ADDRESS

EMAIL ADDRESS CURRENT OCCUPATION (if retired please provide last occupation held)

CURRENT EMPLOYER

Deakin University CRICOS Provider Code: 00113B

Alumni Relations Office Melbourne Burwood Campus, 221 Burwood Highway, Burwood, VIC 3125

Tel 03 5227 1019 [email protected] www.deakin.edu.au/alumni

mailto:[email protected]


DEAKIN/ANTECEDENT INSTITUTION QUALIFICATIONS (if applicable)

NAME OF DEGREE YEAR OF GRADUATION

INSTITUTION

DEGREE 1 DEGREE 2 DEGREE 3

STEP 2 OF 7 NOMINATOR DETAILS (*please complete all fields)

TITLE (Dr, Mr, Ms etc.)

FULL NAME

SUFFIX (OAM, AM) RELATIONSHIP TO NOMINEE

TELEPHONE NUMBER

MOBILE PHONE NUMBER PREFERRED POSTAL ADDRESS

PREFERRED EMAIL ADDRESS

CURRENT OCCUPATION (if retired please provide last occupation held)

CURRENT EMPLOYER





STEP 3 of 7 AWARD CATEGORIES (select applicable award for consideration) Lifetime Achievement Award

Open to any Deakin graduates, who over the course of their lifetime have built an outstanding reputation and have demonstrated both exceptional and prolonged achievement in their professional and/or community endeavours. Alumni of the Year Award

Open to any Deakin Alumni member aged 40 years or over (at the time of nomination) that has consistently demonstrated outstanding success in their professional and/or community endeavours. Young Alumni of the Year Award

Open to any Deakin Alumni member aged under 40 years of age (at the time of nomination) that has demonstrated outstanding success in their professional endeavours, and/or community endeavours.

Alumni Community Service Award

Open to any Deakin Alumni member and recognises the work of an outstanding individual who has consistently demonstrated:

• Outstanding volunteer leadership and service to Deakin University, enhancing the affiliations between Deakin’s alumni, students and the broader community and thereby helping to drive core university goals; and/or

• Significant voluntary contributions which have led to enduring positive outcomes for the wellbeing of others within their community





STEP 4 OF 7 SUPPORTING STATEMENT AND RESUME/BIOGRAPHY In less than 500 words state why as nominator, this person should be considered for the award, ensuring you address how this person meets the selection criteria for the specific award. This précis should include a detailed chronological list of positions held and achievements.

Note any additional wording over 500 will not be considered.





STEP 5 OF 7 NOMINEE’S REFEREES (*please provide the details of two referees)

REFEREE 1

FULL NAME

RELATIONSHIP TO NOMINEE PREFERRED TELEPHONE NUMBER

PREFERRED EMAIL ADDRESS CURRENT OCCUPATION (if retired please provide last occupation held)

CURRENT EMPLOYER

REFEREE 2

FULL NAME

RELATIONSHIP TO NOMINEE PREFERRED TELEPHONE NUMBER

PREFERRED EMAIL ADDRESS CURRENT OCCUPATION (if retired please provide last occupation held)

CURRENT EMPLOYER





STEP 6 OF 7 OTHER SUPPORTING EVIDENCE (optional) You may wish to include any other important information you think relevant to support this nomination. This may take the form of links to: media articles, electronic media, websites etc. (up to a maximum 3 items of supporting evidence) ☐ I have supplied a link with additional information in support of this nomination OR ☐ I do not wish to supply any other supporting evidence STEP 7 OF 7 NOMINATION CHECKLIST, CONFIRMATION AND SUBMISSION CHECKLIST Please check each box in the checklist below to ensure you have included all necessary information and supporting documents. I have included in this nomination (please check): ☐ A fully completed nomination form ☐ A statement supporting the nomination, addressing the selection criteria ☐ Contact details for two referees ☐ Other supporting documentation (if applicable) CONFIRMATION ☐ I acknowledge that submitting this nomination form does not imply in any way that the nominee will be selected to receive an award. ☐ I understand that this nomination and all supporting documentation are confidential





SUBMISSION OF NOMINATION All completed nominations must be attached and emailed to [email protected] .Your nomination must be submitted to the Deakin University Alumni Relations Office by 5pm (AEST) Monday 1 June 2015. Nominations will only be accepted by via email using the prescribed nomination form.




mailto:[email protected]

Deakin University Alumni Awards Nomination form 2015 · 2015-04-30 · Deakin University Alumni...

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