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Chief Minister’s Medal nomination form
Please indicate with an X which medal category you wish to nominate:
Chief Minister’s Medal	2025 Outstanding Aboriginal Leadership Medal
Details of person being nominated: Please provide details for the person you are nominating. The information provided will remain confidential.
Title
Surname	Given names
Current position	Division/unit
Agency	Region
Home postal address
Details of person submitting nomination Please complete this section with your details.
Name
Current position	Division/unit
Agency	Telephone
Email
Signature	Date
Referees List the names of persons who have provided referee statements to support the submission.
Name
Current position
Agency
Name
Current position
Agency
Chief Executive Officer endorsement I understand that should the above nominee be awarded a medal, my agency will ensure a ticket is allocated to the medal recipient and their chosen guest at the event. I proudly endorse this nomination on behalf of the agency:
Name
Signature
Date
Submission statement Use the space provided or attach a separate statement addressing the following headings (1200 words max.)
How the nominee has displayed outstanding and commendable service:
How the nominee’s key achievements impacted their agency and its clients:
If relevant, please provide other comments to support the submission
Checklist When submitting your nomination form, please ensure the following:
All sections have been completed	Y/N
Total word count for the submission statement does not exceed 1200 words (exclusive of referee statements)	Y/N
Supplementary material is attached (if applicable)	Y/N
There must be a minimum of two but no more than two referee statements	Y/N
Submission is signed by your agency’s Chief Executive Officer	Y/N
Submission must be lodged by Friday 20 June 2025	Y/N
Lodging a nomination Nominations must be submitted to your agency’s Office of the CEO electronically using this nomination form and be clearly marked. Nomination - Chief Minister's Medal in the subject title. Your agency’s CEO will shortlist a maximum of three nominations and submit the shortlisted nominations electronically. Email: CMAwards.CMC@nt.gov.au Closing date: Submissions must be received by the Office of the Commissioner for Public Employment by Friday 20 June 2025. Nominations received after the closing date will not be accepted. For more information please contact Strategic Workforce Planning and Development Office of the Commissioner for Public Employment Phone (08) 8999 4115 Email CMAwards.CMC@nt.gov.au Privacy We have collected your personal information which will be handled in accordance with the Northern Territory Information Act 2002. Your personal information is not required to be provided, however, if you do not, we may not be able to accept your nomination. For more information on how we handle your personal information, please refer to the Department's privacy policy.
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