Cover Nominations

Nomination Form

Thank you for taking the time to nominate a local who has made a contribution to the community, to feature on the White Pages and Yellow Pages under the cover theme "Keeping Our Communities Healthy".

As a reminder, we are looking for people making their communities a healthier place. Whether they’re tireless charity fundraisers, ingenious doctors or warm-hearted volunteers, Sensis is searching for Australia’s health care heroes.

From the nominations we receive, the shortlisted nominees will be contacted by The PR Edge, who is assisting Sensis with the Covers Program, with the chosen person to appear on the cover of their local 2012/13 Yellow Pages and White Pages directory.

Three simple steps will complete your nomination:

Step 1 - Check closing dates by directory region to ensure nominations are still open

Step 2 - Review the selection criteria as outlined in the article http://whitepagescommunity.com.au/content/calling-all-aussie-health-heroes

Step 3 - Check that your nominee is happy for you to provide this information to us, and if so please complete the nominations form below.

Alternatively you can write to The PR Edge, Building 3, 658 Church St, Richmond VIC 3121 or fax 03 8416 6779

Nominations will be treated in strictest confidence and in accordance with the Sensis privacy statement available at www.about.sensis.com.au

Your details

Region for which you are nominating: *

Title: *

First Name: *

Last Name: *

Email address: *

Contact phone number: *

Nominee’s details

Title: *

First Name: *

Last Name: *

Town/Suburb: *

State: *

Email address (optional):

Contact phone number (optional):

To submit your nomination, in 200 words or less, describe how the nominee has made a positive impact in your community according to the theme criteria: *