DETAILS OF NOMINEE:

Area of excellence (sport, arts, industry etc.)

Full name (required)

Address (if deceased, address of relative) (required)

Birthdate (required)

Place of birth of nominee (required)

Place of death (if applicable)

Date of death (if applicable)

Nominee phone number

Nominee email

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NOMINATOR INFORMATION

Your name (required)

Your address (required)

Your phone number (required)

Your email (required)

Today's date (required)

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