Nomination Form

My nomination for a Positive Action Award 2012 is:

Name of Business, Organisation or Individual

Their Address:

Their Telephone Number(if known):

Their Email Address (if known):

I think my nominee should receive an award because:

Please give us contact details about yourself. This information will be used only to verify your entry and to clarify details in your nomination. We regret that we cannot accept anonymous nominations, or nominations with false contact details.

My Name is:

My Business or Organisation (if applicable):

My Address:

My Telephone Number:

My Email Address(if applicable):

I am willing to attend the award ceremony if my nomination is successful:

 Yes
 No