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Esme Tombleson Award Nomination Form
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The Esme Tombleson Award recognises those that have made a significant contribution nationally to MSNZ and people impacted by MS.
Nominations close 31st October annually.
Details of the Nominee
Persons name
*
First name
Last name
Email address
*
Cell phone
*
Other phone
Date of birth
Address
*
Address line 1
Address line 2
Address line 3
Address line 4
Town/Suburb
City
Postcode/Zip
Is the nominee connected to an MS Regional Society?
*
Yes
No
Please select which Regioanl Society the nominator is connected with
Northland Multiple Sclerosis Society Incorporated
Multiple Sclerosis Auckland Incorporated
MS Waikato Trust
Bay of Plenty Multiple Sclerosis Society Incorporated
Rotorua and District Multiple Sclerosis Society Incorporated
Hawke's Bay Multiple Sclerosis Society Incorporated
The Gisborne and East Coast Multiple Sclerosis Society Inc
Taranaki Multiple Sclerosis Society Incorporated
Wanganui Multiple Sclerosis Society Incorporated
The Manawatu Multiple Sclerosis Society Incorporated
The Wellington Multiple Sclerosis Society Incorporated
Nelson Multiple Sclerosis Society Incorporated
Marlborough Multiple Sclerosis Society Incorporated
MS West Coast Incorporated
Multiple Sclerosis & Parkinson's Canterbury Charitable Trust
South Canterbury Multiple Sclerosis Society Incorporated
Southland Multiple Sclerosis Society Incorporated
Otago Multiple Sclerosis Society Incorporated
Details of the Nominator
Nominators full name
Email address
*
Confirm Email address
Cell phone
*
Other phone
Nominators Address
Is the nominator connected to an MS Regional Society?
Yes
No
Please advise the Regioanl Society the nominator is connected with
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Esme Tombleson Award Nomination Form
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Is the Nominee...
A person with MS
A family member of a person with MS
A carer of a person with MS
A friend of a person with MS
A supporter of MS
Has the nominee been recognised by any other awards?
Please list the other awards the nominee has been recognised for.
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Esme Tombleson Award Nomination Form
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The Esme Tombleson Award recognises those who have made a significant contribution to people impacted by MS on a NATIONAL level.
What specific actions has the nominee taken to support people impacted by MS nationally, and what impact have these actions had?
What motivated you to nominate this person, and what do you believe sets them apart from others?
Is there any other relevant information you would like to share with the Award Committee regarding the Nominee?
If applicable, describe how the nominee has provided an outstanding contribution to people impacted by MS in their local community? Regional contributions are not a requirement but useful to give a wider picture of their contribution.
Share any success stories or examples of individuals or communities that the nominee has helped?
How has the nominee collaborated with MS organisations or individuals to make a greater impact to the lived of those living with MS in NZ?
How has the nominee engaged with people impacted by MS to ensure their voices are heard and their needs are met?
Finally, is there anything else you would like to share with us about why this person deserves recognition for their contributions to people impacted by MS in NZ?
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Referees
Please include the names and contact details of two people who are willing to be contacted in support of the nomination.
Name of Referee (1)
Phone
Address
Email
Name of Referee (2)
Phone
Address
Email
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Esme Tombleson Award Nomination Form
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Nominee Approval
The consent of the person being nominated is not required. The nominee SHOULD NOT be informed that they have been nominated, as it is not fair to raise expectations in case they are not met.
All nominations are treated in the strictest confidence. No information regarding the nominee or the details of the nomination is divulged.
Once the Award Committee have agreed on the recipients they will be contacted and asked for their consent to accept the award and for this to be publicly notified.
Declaration
I confirm that the information contained in this application is true and correct and completed in full.
Yes
No
I confirm that the nominee has not been made aware of their nomination.
*
To the best of my knowledge the Nominee IS NOT aware of the nomination
The Nominee IS aware of the nomination
I'm not sure
I have a letter of support from MSNZ or an MS Regional Society that I will attached when this form is submitted
You will receive an email you can reply to and attach the letter of support.
Yes
No
I am aware and accept that the personal information collected about me and the nominee in connection with this application will be used by the Selection Panel for the purposes of assessing this application only.
Yes
No
I confirm that I am happy to be contacted if more information is required by MSNZ or the Award Committee.
Yes
No
I agree to the Conditions of Entry as detailed on the Criteria.
Criteria can be viewed https://msnz.org.nz/esme-tombleson-award-nomination-application-form/
Yes
No
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Would you like to receive our monthly e-newsletter MS Voice?
No
Yes
Would you like to receive our bi-annual donor mail?
Yes
Would you like to receive further information reguarding leaving a gift in your Will to MSNZ
Yes
Would you like to receive our FREE Living Well with MS Pack?
Yes
Would you like to be connected to your local Regioanl MS Society?
Auckland
Bay of Plenty
Canterbury
Canterbury - South
Gisborne
Hawke's Bay
Manawatu & Central
Marlborough
Nelson
Northland
Otago
Rotorua & District
Southland
Taranaki
Waikato
Wellington
West Coast
Whanganui
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Please check the highlighted fields
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