Online Individual Nomination 

Southwark Civic Association                                             

Individual nomination form 

Name of person being nominated:

Address of person being nominated:

Their age, if known:

Your relationship to the person, ie friend, 

you MUST NOT be related

Nature of the work the nominee is doing e.g. charity:

Is the work paid or voluntary

How long has the person been doing this work?

How long have you known this person?

You can also nominate a person for a specific heroic act or an individual act or acts which have benefited your community.

Do you work for Southwark Council or are you a member of the Southwark Civic Association

Yes No 

This box is designed to allow you to add as much detail as possibly can, as the decision of the association will be based solely on this form

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Your Name:

Your Telephone Number:

Your Email Address:

If required please contact me by:

Email Telephone 

Please note that Southwark Civic Association is an independent, non political organisation. Please ensure that your nominations are not for political organisations or representatives.