WA Women's Hall of Fame Nomination Form

To submit on-line, please complete ALL details on the form below

Nominations can also be mailed to:
The WA Women's Hall of Fame Secretariat
20 Henry Lawson Walk, East Perth WA 6004
or contact us on: 0439 820 177
E-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

* - indicates required field

Nominee Details

Nominees Name *
Title *
(eg. pioneer, author,
volunteer, scientist etc)
Daytime Phone
(No Spaces)
Email
Date of Birth
(dd/mm/yyyy)
Nomination Submitted by *
Submitter Details
Title/Occupation
Nominees's association to Submitter *
Submitter Address
Submitter Daytime Phone * (No Spaces)
Submitter Mobile * (No Spaces)
Submitter Email *
Reasons for Nomination

The 2012 WA Hall of Fame Inductees will be selected for distinction in one of the following five categories. In which category are you nominating this WA Woman?

Why are you nominating this West Australian woman in the above category for the WA Women’s Hall of Fame? (further supporting documentation can be attached using the field below)
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How do you believe your Nominee has contributed to her community, and/or to Western Australia, what do you believe her greatest achievements are?
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What lasting impact has your Nominee's actions/dedication/achievements had in her local community, or to WA?
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How do you believe your Nominee has helped foster, inspire, or encourage young/other West Australian women? Why is she a good role-model?
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Enter Secret Code

Photo (2mb limit)
JPG GIF PNG files only
Nominee's Current
Postal Address
If you are not enclosing a photo, is one available upon request?
Please Note: Nominees must be current residents of Western Australia
Attach further documentation

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