Premier Sports Awards

1. Personal Details

Category:

Title (e.g. Ms/Prof/Dr/Mr):

Surname:

FirstNames:

NickName:

ID Number:

Home Language:

Marital Status:

Postal Address:

Tel Number (Work):

Tel Number (Home):

Cell Number:

Fax Number:

Have you won a Premier's Sports Award previously?:
Yes No

If yes, when and in what category?:

Full name of the representative/s who will receive the award on behalf of yourself/team/sports person should you not be available:

Representative Tel (Home):

Representative Tel (Work):

Representative Cell:

Representative Fax:

Fill in the contact details, if available

In the event of you being nominated for an award, where should the notice be sent to?

Contact person:

Contact Telephone:

Contact Fax Number:

Contact Email:

2. Achievements

In which Code of Sport was your achievement?:

Achievement Date:	Achievement Level:	Achievement:

Additional Info:

3. Referee's Details

Please submit the details of a referee who will be able to verify the information completed above

Referee Name:

Tel No (Home):

Tel No (Work):

Cell No.:

Email Address:

Fax No. :

4. Submitted By:

Organisation:

Enter name of person submitting the form

Name of person completing the form:

Cell No. /Tel No:

Date:

Name of the head of the organisation:

Cell No./Tel No:

Date:

Name of committee member:

Cell No./Tel No:

Date:

Cancel Send