2013 Sport SA Official of the Year Award Nomination Form ______

SECTION 1: Personal details of the Nominee Title: Mr Mrs Miss Ms Family Name: Given Name(s): Phone: Mobile: Address: Suburb: Post code: Email Address: Date of Birth: Sport:

SECTION 2: Details of the Organisation submitting this Nomination

These details are required of the organisation submitting the nomination and will be used for the purpose of obtaining more information if necessary. What is the highest level of competition available in this sport? Club Regional State National International Contact details: Organisation / Club: (1) Name of Contact: Position in Organisation: Phone: Mobile: Email Address: Website Address:

State Sporting Organisation endorsement: (2) Name of State Sporting Organisation: Name of CEO / General Manager / President: Phone: Mobile: Email Address:

Signature: (Electronic signatures accepted) Date: X

2013 Official of the Year Award Proudly sponsored by Club One Page 1 of 2 SECTION 3: Achievements Criteria

The Sport SA Official of the Year will be an individual who has attained a level of excellence in the field of officiating e.g. refereeing / umpiring / judging / medical services / technical officer and whose performance sets them apart from their peers. This award recognises an outstanding South Australian official who has demonstrated dedication, skill knowledge and expertise in officiating at any level or who has made a significant contribution to the standard of officiating in the state.

Highlight the qualifications and major achievements by the nominated person to their sport.

16th September 2012 to 16th September 2013.

SECTION 4: Additional documentation to be supplied For promotional purposes, please summarise the Nominee’s contribution to their sport(s), in 60 words or less (restricted to the last 12 months only). Please also provide a recent photograph (head and shoulders, electronic high resolution version) of the Nominee for promotional purposes (this information will be used for any announcement / presentation functions).

In signing this nomination, I acknowledge that the nominee for Official of the Year meets the Award criteria, has accepted the nomination and abides by our own code of conduct.

Signature: (Electronic signatures accepted) Date: X

Notes: (1) Organisation must be a member of Sport SA, or a club affiliated with a Sport SA member. Club nominations must be endorsed by the State Sporting Organisation (who is a member of Sport SA). (2) Only required if the nominating organisation is not the State Sporting Organisation. Nominations close 5pm Monday 16th September 2013. Late entries will not be considered. Please send this form and any attachments to: Sport SA Awards PO Box 103, WEST BEACH SA 5024 Or [email protected] For more details please visit www.sportsa.org.au .

In signing this nomination, I acknowledge that the nominee for Official of the Year abides by our sports code of conduct.

2013 Official of the Year Award Proudly sponsored by Club One Page 2 of 2