COPY - Nomination form Community Consultation Committee

First name

Last name

Phone number

Stakeholder group represented and position within the group (if relevant):

Address

Postcode

Suburb

Postal address if different from above

Length of time in Geraldton or the Mid West?

Please tell us why you wish to join the CCC? please outline any skills or experience you believe will be valuable to the committee (300 words)

I declare all statements provided above are true and accurate

YesNo

Date submitted

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