Recognition of Service to Local Government Form

Required fields are marked with an asterisk (*).

After you successfully submit this form you will receive a confirmation email. Please verify that you receive this email to confirm your submission was successful. If you have any problems with this process, please contact the LGA at

Recipient details
(Please add full name to be printed on certificate)
Please provide any post nominal letters to be printed on the certificate (ie OAM)
Please write the full name of the recipient's council. (To be printed on the certificate.)
Category of Recognition of Service
Please select if the recipient is currently serving as an Elected Member, staff member or volunteer to the council.
If recipient has served as a combination of as an Elected Member and/or as a staff member or a volunteer for Local Government, please provide date ranges and names of each council represented.
Was the service continuous? *
Was the service completed at one council? *
Elected Members only - Certificate Presentation
Would the nominated Elected Member like to receive the certificate at an LGA Networking Dinner?
Please outline the person nominated key achievements and any other key information that will help inform the presenter about the nominated persons service to Local Government and the community they serve within. (Approx 2 paragraphs)
Please upload a profile picture of the nominated Elected Member. (Preferably a high resolution jpeg)
Certificates to be posted to Council
Key contact person