Angus Stewart Achievement Awards
Post Secondary Nomination Form
The Angus Stewart Achievement Awards recognise
academic and social achievements of tertiary students (up
to 29 years of age), who are blind or vision impaired.
Three prizes will be awarded - $750 to the winner and two
runner up prizes of $500 each.
This form is to be completed by the nominee or a nominator.
Individuals may nominate themselves, or be nominated by a
friend, parent, educator or community member.
All nominees will be invited to attend the Awards Ceremony
(date to be advised). Winners will be notified prior to the
ceremony.
Please take note of the following points:
 Nominations must address every criterion
 Please attach any relevant, supporting documentation
to your application (i.e. reports, certificates, academic
transcripts)
 Application forms become the property of VisAbility;
please do not send original copies of certificates etc.
 The nominee must sign the nomination form
1
 VisAbility has the right to release details of the nominee
to the media, unless the nominee specifically requests
that they do not wish to receive publicity
 The nominee must be a resident of Western Australia
2
Nominee Information
Name:
Address:
Telephone:
Email:
Date of birth:
Date of application:
Please indicate the extent of your vision impairment:
Vision Impaired, Legally Blind, Totally Blind
Nominator Information (if applicable)
Name:
Address:
Telephone:
Email:
Relationship to nominee:
Education Institute/Organisation Information
Name of education/tertiary institute:
Address:
Telephone:
Email:
Name of course:
Expected date of completion:
Mode of study: Full time ( ) Part time ( )
3
Note: If you have studied multiple courses in 2014 please
include further details under ‘Additional Information’
4
Section One: Academic Achievement
Please outline the nominee’s academic achievements.
Academic reports should be supplied and if in code should
be accompanied by an explanatory key.
5
Section Two: Personal Development
Please outline any personal development programs or
activities the nominee has participated in (300 words or
less).
6
Section Three: Social, Cultural and Sporting
Activities
Please outline any social, cultural and/or sporting activities
the nominee has participated in (300 words or less).
7
Section Four: Awards
List details of any awards, prizes, presentations or
scholarships that the nominee has ever received. Please
include the date the award was received.
8
Section Five: Additional Information
Please provide any additional, relevant information here
(300 words or less).
9
NOMINATOR SIGNATURE:
DATE:
NOMINEE SIGNATURE:
DATE:
Entries can be sent via mail:
Att: Michelle Frith
Community Relations
Awards Program
VisAbility
PO Box 101
Victoria Park, WA 6979
Or email: michelle.frith@visability.com.au
For further information please visit our website:
www.visability.com.au
If you have any questions or would like to discuss your
application please contact:
Michelle Frith
Public Relations - Community Relations
(08) 9311 8241
michelle.frith@visability.com.au.
Entries close Friday 31 October 2014
10