Nomination Form

First Name*
Middle Name
Last Name*
Title*
Date of Birth*
Place of Birth*
Position Title*
Company*
- Australian Aboriginal Origin
- Torres Straight Origin
Office Phone*
Mobile Phone*
Email*
Address*
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Campaign Region*
Industry*
What community involvement does the nominee have?*
- Sporting Groups
- Local Council
- Chamber of Commerce
- Community clubs and organisations
- Church/faith-based groups
- School organisations
What is the nominee's motivation for being an Ambassador?*
Have you been involved in any White Ribbon or Violence Against Women activities prior to you nomination?*
Will you speak at public events in your local area?*
Will you speak at school events?*
Are you prepared to travel for speaking engagements?*
Are you prepared to attend Ambassador training events?*
Would you be able to run a fund raising event for White Ribbon?*
Would you be interested in attending fund raising events for White Ribbon?*
How else the nominee be involved?*
How can we best support you?*
Do you know anyone who would be interested in being an Ambassador?*
Declaration to be signed by the nominated individual*
- I am self nominating
Nominator’s full name
FirstLast
Nominator's Organisation
Nominator's Email Address
Nominator's Phone
Nominator's Mobile
Anti-Spider Captcha