Online Organisation Nomination

Southwark Civic Association 

Organisation nomination form

Name of organisation being nominated: 

Address of organisation being nominated: 

Type of organisation, ie Charity, voluntary, private:

Your relationship with the organisation, ie employee, customer, client:

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.