Read the Changemaker Award Guidelines

Note: 

Amendment to Section 4. Part C. Written Reference. 

References are optional and can come from within the nominee's or nominating organisation or from any individual.

Nominator Details

Nominator First Name *

Nominator Last Name *

Nominator Organisation (leave blank if nominating as an individual)

Nominator Email Address *

Nominator Phone number *

Briefly describe your connection to the nominee *

Have you informed the nominee about this nomination and obtained their consent? *

YesNo

Are you nominating an *

IndividualOrganisationProgram/Project

Nominee Details

Nominee full name *

Primary contact person (only if nominating an organisation, group, program, or initiative)

Select the main region connected to the nominees work *Alice SpringsGreater DarwinKatherineManingridaNhulunbuyTennant CreekWest DalyOther

Nominee email

Nominee phone number *

Please provide a brief description on the nominee and their work (maximum 300 words) *

Eligibility

Is the nominee based in, living in, working in, or operating in the Northern Territory? *

YesNo

Is this nomination about work that contributes to ending domestic and family violence? *

YesNo

Which best describes the nominee's work? *

VolunteerPaid work Other

If you selected other, please describe other work. *

If it is a paid role, is the nominee the principal or owner of the business or organisation? *

YesNo

If the nomination is in relation to paid work, please upload an endorsement from the nominee's organisation

YesNo

Not required if the nominee is the principal or owner of the business/organisation.

Upload a signed letter or statement of approval

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Nomination Statement

What does the nominee do, and how does this contribute to ending domestic and family violence? (Maximum 250 words) *

Why does this nominee deserve to be recognised as a ChangeMaker? (Maximum 150 words) *

Community Relevance

Which community does the nominee serve and how does their work contribute to positive change in that community? *For community this might be a place — a town, remote community, or region — or a group of people, such as young men, women escaping violence, a particular cultural community, a sport organisation or a workplace.

What is the breadth or reach of the nominee's work? (Maximum 150 words) *

References

Reference 1 full name

Enter their position, role, or community role

Reference 1 relationship to the nominee. Explain how they know the nominee and their work.

Reference 1 email address

Reference 1 phone number

Reference 1 - How would you like to provide your support statement

I will upload a file/documentI will write a statement/text

Reference 1 - File Upload

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Reference 1 support statement. (Maximum 300 words) *

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Do you have a second referee that could strengthen your nomination? (Not compulsory)

Reference 2 full name

Enter their position, role, or community role

Reference 2 relationship to the nominee. Explain how they know the nominee and their work

Reference 2 email address

Reference 2 phone number

Reference 2 - How would you like to provide your statement?

I will upload a file/documentI will write a statement/text

Reference 2 - File Upload

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Reference 2 support statement. (Maximum 300 words)

Do you have a third referee that could strengthen your nomination? (Not compulsory)

Reference 3 full name

Enter their positions, role, or community role

Reference 3 relationship to the nominee. Explain how they know the nominee and their work

Reference 3 email address

Reference 3 phone number

Reference 3 - How would you like to provide your statement?

I will upload a file/documentI will write a statement/text

Reference 3 - File Upload

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Where did you hear about the Changemaker Awards *Direct from a NO MORE/CatholicCare NT employeeSocial MediaNewsletterNetworkSomeone in my organisationOther

Declaration

I confirm the information provided in this nomination is true and correct to the best of my knowledge *

I confirm the nominee is aware of and consents to this nomination *

I understand that nominee and winner details, including name, image, region, and summary of work, may be published publicly  *

I understand that incomplete nominations may be deemed ineligible if requred information is not provided *

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