CSSC Sports & Leisure - The Merit Award Scheme 2010 Nomination Form

Name of nominee: Please print name with title and honours.*

Date of Birth: (dd/mm/yyyy)

Contact Address:

Postcode:

Contact Number (home):

Contact Number (work):

Email Address:

Employing Department or Previous Department:

Office Address:

Postcode:

Details of all Voluntary Positions held by Nominee:

Voluntary Position 1

Position:

Constituent Body (e.g. Area, region, SRB, DA):

Dates:

Voluntary Position 2

Position:

Constituent Body (e.g. Area, Region, SRB, DA):

Dates:

Voluntary Position 3

Position:

Constituent Body (e.g. Area, Region, SRB, DA):

Dates:

In respect of each of the nominee’s roles, please give details of the quality of service provided, the attitude and approach of the individual and changes they introduced or developments they made in sport or administration. Remember to qualify for a Merit Award an individual must have made a positive and distinctive contribution to CSSC. If you require any assistance with obtaining details of previous voluntary service, please contact Hedley Featherstone on 07802 482330 or via e.mail hedley.featherstone@cssc.co.uk hedley.featherstone@cssc.co.uk"/>

Name of Nominator (Please print full name):

Constituent Body:

Position of Nominator:

Contact Address:

Postcode:

Daytime Contact Number:

Email Address:

Date Form Completed: