NOMINATION FORM – SAFETY ADVOCACY AWARD

All fields marked with * must be completed

YOUR DETAILS

Name:*

Email:*


NOMINEE DETAILS

Company:*

Contact name:*

Position title:

Street address:*

Suburb:*

State:*

Postcode:*

Phone:*

Email:*


AWARD DETAILS

Please summarise the career highlights of the nominee:*
Suggested maximum 200 words

Please outline how the nominee has improved safety conditions at their workplace:*
Suggested maximum 300 words

Please provide details of any innovative programs or solutions the nominee has implemented within the workplace:*
Suggested maximum 300 words

You may attach up to three (3) supplementary files (photographs, diagrams, maps, etc.):
Combined file size must not exceed 10MB
1.
2.
3.

How did you hear about the Prospect Awards?
 Australian Mining magazine

 www.australianmining.com.au
 Safe to Work magazine
 Safe to Work e-newsletter
 www.safetowork.com.au

 Word of mouth
 Other (please specify)


TERMS & CONDITIONS

1. By submitting a nomination, you give permission for Australian Mining to publish information about your company and project.
2. You also consent to Australian Mining and parent company Prime Creative Media collecting your information, and to receiving information on other events and publications. Your contact information will not be disclosed to any third parties.
3. If nominating on behalf of another company or person, Australian Mining and Prime Creative Media relies that you have authority to act on behalf of this company or person to submit their information and consent to the terms & conditions on their behalf.
 Yes, I accept the terms & conditions