2016/17 Nomination Form** Nominations Close 2 March 2018 **

(Nominees must be must be female and a current Elected Member of a South Australian Council at the time of the call for nominations)

Name of Nominee Title First name Surname

Home Address of NomineeNominee’s telephone NumberNominated by (Council or organisation name)

Contact details of person submitting the nomination

Name:Council/Organisation:Telephone: Email:

Return this completed form and supporting documentation where appropriate (no more than four A4 single-sided pages in total) that will assist the judging panel in assessing nominations to rebecca.wake@lga.sa.gov.au by 2 March 2018.

Nominees’ name: Council:

Specific Example/sHave made a significant contribution to their Council &/or Community during the 12 months prior to the award being made

Demonstrate the achievement of a beneficial outcome to the Council &/or Community through innovation, leadership, collaboration and vision

Have provided inspiration to other women to become further involved in the work of their Council &/or Community

Exhibit the ability to promote the diverse perspectives of women in Local Government.

ECM 591378 Local Government Association of South Australia