I agree to be nominated for a 2015 Victorian homelessness achievement award. I agree that the Council to Homeless Persons or its agents may use the information provided in this form to assess nominations for the awards and for publicity purposes associated with the awards. I consent to the Council to Homeless Persons or its agents contacting the people named in this form and seeking comment from them regarding this nomination. I acknowledge that the Council to Homeless Persons will store this information securely. Name: Signature: Your declaration: By submitting this nomination for the Victorian homelessness achievement awards I certify that all information provided is true and correct to the best of my knowledge. I agree that the Council to Homeless Persons or its agents may use the information provided in this form to assess nominations for the awards and for publicity purposes associated with the awards. I consent to the Council to Homeless Persons or its agents contacting the people named in this form and seeking comment from them regarding this nomination. I acknowledge that the Council to Homeless Persons will store this information securely. Name: Signature:
I agree to be nominated for a 2015 Victorian homelessness achievement award. I agree that the Council to Homeless Persons or its agents may use the information provided in this form to assess nominations for the awards and for publicity purposes associated with the awards. I consent to the Council to Homeless Persons or its agents contacting the people named in this form and seeking comment from them regarding this nomination. I acknowledge that the Council to Homeless Persons will store this information securely. Name: Signature: Your declaration: By submitting this nomination for the Victorian homelessness achievement awards I certify that all information provided is true and correct to the best of my knowledge. I agree that the Council to Homeless Persons or its agents may use the information provided in this form to assess nominations for the awards and for publicity purposes associated with the awards. I consent to the Council to Homeless Persons or its agents contacting the people named in this form and seeking comment from them regarding this nomination. I acknowledge that the Council to Homeless Persons will store this information securely. Name: Signature: