Nomination form

Nominations open 18 May – 31 July 2023. Winners will be announced on or before 31 December 2023.

If you would like to get in touch with us about nominations, please call Queensland Museum on (07) 3153 7838.

Nominator details

Contact information for the individual submitting the nomination.

TitleFirst nameLast nameMobileEmailRelationship to the nominee

Nominee details

Contact information for the individual being recommended for the Queensland Museum Medal.

TitleFirst nameLast nameMobileEmailWebsiteDoes the nominee have any previous history with Queensland Museum Network or prior recognition of their achievements elsewhere? (e.g. Order of Australia, industry awards)

Referees

Contact information for up to three persons who can substantiate claims made in the nomination.

Referee one

TitleFirst nameLast nameMobileEmailRelationship to the nominee

Referee two

TitleFirst nameLast nameMobileEmailRelationship to the nominee

Referee three

TitleFirst nameLast nameMobileEmailRelationship to the nominee

Nomination

In 1,000 words or less, describe the nominee’s outstanding achievements of excellence in their chosen field. Using examples, demonstrate the impact and link between these achievements to Queensland Museum Network and, by extension, the Queensland community. Justify how these achievements are deserving of the Queensland Museum Medal*. Each nomination will be assessed against the following equally weighted criteria: 1. Contribution to Queensland Museum Network. 2. Impact in the wider community. 3. Excellence in their field. Please ensure that all claims can be substantiated by listed referees.

Please write your response

Approval

Checking this box forms your signature and confirms that all information provided on this form is accurate and true to the best of your knowledge*

More information

For more information on making a nomination for the Queensland Museum medal, contact: Office of the Chief Executive Officer Queensland Museum Network Phone: 3153 7838 Email: qm.directorate@qm.qld.gov.au

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Queensland Museum will only use the personal information you submit in this form to answer your questions, to provide you with the information you have requested or to make requests regarding your question. Further information about the types of information collected and stored by Queensland Museum can be found on our website: http://www.museum.qld.gov.au/privacy-and-security-statement.

Fields marked with an asterix (*) are required.