The annual Seniors Award is administered by the Welfare of the Elderly Committee of the Club and recognises the contribution of men or women over the age of 60 who give outstanding service in a voluntary capacity to older people in our community.
If you, or someone that you know, appears to fulfill the required criteria, and would like the Club to consider you/them for this award, please complete the Electronic Expression of Interest Form below.
Kindly note that this form must be completed all at the one time as it cannot be saved. If it is closed during completion, all information added to that time will be lost and have to be re-entered. Before commencing the addition of your data, please scroll down through the form to familiarise yourself with the type and amount of information required.
Please note that the submission of this form incurs no liability, or obligation, to any party, on the part of Rotary Club of Melbourne Inc, in relation to the consideration of candidates and/or any decision(s) pertaining to this Award.
Are you nominating a candidate, or are you nominating yourself?
If you are nominating SOMEONE ELSE, what is your relationship with, or connection to, the Candidate?
If you are nominating SOMEONE ELSE, which is the best way to contact you?
Your Phone Number
Your Mobile Phone Number
Your Email Address:
Your Mailing Address:
Full Name Of PERSON BEING NOMINATED ("the Candidate"):
Is the Candidate aware that they are being nominated for this award?
What is the Candidate's gender?
When it becomes necessary, which is the best way for the Club to contact the Candidate?
Candidate's Phone Number:
Candidate's Mobile Phone Number:
Candidate's Email Address:
Candidate's Mailing Address
What is the approximate age of the Candidate?
Please attach Candidate's photo (head & shoulders) if available.
What is the nature of the Candidate's service to older people?
Which organisation(s) has the Candidate worked with/for to deliver their service to older people?
How long has the Candidate undertaken service to older people?
Has the candidate's service to older people been continuous throughout this period?
Was/is the Candidate's service to older people performed on a voluntary basis?
Has the Candidate received any other formal recognition for their service to older people?
If "Yes" to the previous question, what was the nature of that formal recognition and when, and by whom, was it awarded?
Please add any further comments in support of the nomination of this Candidate.
You may attach here any additional documentation in support of the nomination:
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