NOMINATION FORM

1. NOMINEE’S First name

2. Last Name

3. Date of birth

4. Age on November 4, 2021

5. Ethnic origin

6. Address 1 – House number and street

Address 2 – Village/Town or City

Postcode

7. If not resident in Yorkshire, where in the county were you born

8. E-mail address

9. Home phone number

10. Mobile phone number

11. Company/organisation (where applicable)

12. Current school/college/university (where applicable)

13. Position or job title (where applicable)

NOMINATOR’S DETAILS (If you are nominating someone, please complete the section in green below below:

First Name

Last Name

Address 1 – House number and street

Address 2 – Village/Town or City

Postcode

E-mail address

Home or office phone number

Mobile phone number

Company/organisation (where applicable)

Current school/college/university (where applicable)

Position or job title (where applicable)

How do you know the nominee (e.g. employer, colleague, friend etc)

15. What are your (if self-nominating) or the nominee’s achievements or exceptional contributions? (Max 200 words)

16. Explain why you (if self-nominating) or the nominee deserves this award and what impact your/their efforts have had. Please see entry criteria for more guidance) [Max 500 words]

17. Is there any additional information you would like to give in support of this nomination? [Max 300 words]

18. I CONFIRM THAT THE INFORMATION I HAVE SUBMITTED IS ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND I HAVE ONLY TICKED ONE AWARD CATEGORY (check box)

20. Other (please state) below

Please note:

All completed entry forms must be submitted by 9am on Monday, July 19, 2021

NOMINATION FORM