NOMINATION FORM

NOMINATION FORM(In accordance with the Privacy Act 1993, the Lions Club of Kapiti Charitable Trust undertakes to use the information provided for the sole purpose of activitiesand procedures related to the awards and awards ceremony).Entries close 5.00 pm Friday March 30, 2012 and must be on an official entry form.Please forward to Bill McKeich, 17 Cheltenham Drive, Paraparaumu. Ph. 9056952. Email: yanakie@clear.net.nzAwards will be held at Southwards Theatre, Paraparaumu, 6:30pm Thursday May 3, 2012Nominee’s details:Name:Sport:Address:Contact Phone:Email:Nominated by: ...............................................................................................Email.........................................................................Phone:..........................................I declare the information I have given has been declared valid and truthful by the nominee (nominator’s signature)____________________________Choose the category you wish to enter (see below)Enter the number of the category from the list on the back of the form.Category No Category No Category NoNominee’s credentials: for the period from 1st April 2011 to 31st March 2012.International Achievements (Add extra sheet if necessary)National Achievements (Add extra sheet if necessary)Regional Achievements (Add extra sheet if necessary)Local Achievements (Add extra sheet if necessary)

PHOTOGRAPH!! It is important for awards night production purposes that you attach a full face photograph oran action shot (minimum size 150mm x 100mm) or send by email in Jpg format to yanakie@clear.net.nz.(Photographs are projected onto the big screen at awards nights when finalists/winners are called to the stage) - Inquiries: Bill McKeich on 905 6952 oryanakie@clear.net.nzAWARD CATEGORIES: (Please tick one or more nominated categories)1 Professional Plaques Signs Trophies Sportsman of the Year2 Undercover Secrets Lingerie Sportswoman of the Year3 Nature Coast Team of the Year4 Monteiths Brewery Bar Coach of the Year5 Kapiti Observer Emerging Sportsman of the Year (Aged 14 to 22 as at 31 March 2012)6 Undercover Secrets Lingerie Emerging Sportswoman of the Year (Aged 14 to 22 as at 31 March 2012)7 Cycletech NZ Ltd Sports Personality of the Year8 Coastlands Shoppingtown Sports Volunteer of the Year(Awarded to a volunteer who has displayed outstanding commitment and dedication to sport(s) over time).9 Pritchard Group Ltd Disabled Athlete of the Year10 Whitireia Community Polytechnic Official of the Year11 Sport Wellington Administrator of the Year(Paid or unpaid - this is to acknowledge the work of an administrator who has achieved something outstanding over the last year).12 Simpson Grierson Contributor to Sport of the Year (Awarded to honour past or present contributions to sport)The Pak’nSave Sportsperson of the Year will be chosen by an independent panel of judges from Categories 1 to 6 and 9Conditions of Entry:Performances by nominees will only be considered if they have occurred between 1 April 2011 to 31st March 2012, (except in the case of the Sports Volunteer,and/or Contributor of the Year which is recognition of long term service).All nominees must meet the following residency criteria covering the awards period.(a) Residency in the Kapiti district, or;(b) Be acknowledged as a Kapiti resident but lives elsewhere in order to meet demands of an international sporting career.(c) Represented the Kapiti district in their chosen sport.Nominations will be accepted from all national and regional sports organisations, clubs, media and the general public.