Esme Tombleson Award Nomination Application Form

Esme Tombleson Award Nomination – Application Form

The Esme Tombleson Award recognises those that have made a significant contribution to people impacted by Multiple Sclerosis on a national level. Nominations close annually on 1st November.

Download the Esme Tombleson Criteria 2023 here.
The nomination form can be also downloaded here. Once completed, you can send your nomination to:
Esme Tombleson Award Nomination
MS Society of NZ
PO Box 1192
Christchurch 8011

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Name of Nominee: *

Nominee’s Address: *

Email: *

Phone Number: *

What is the nominee’s association with MS? *

Is the nominee connected to an MS Regional Society? *

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Nominator’s Information (Yours)

Your Name: *

Your Address: *

Your Email: *

Your Phone: *

What is your association with MS? *

Are you connected to an MS Regional Society? *

When completing the following questions you are welcome to attach your information separately along with providing any relevant photographs, press cuttings, letters of support etc.

Please tell us…

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?
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.
Can you 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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More Information Details: *

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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.

Details - 1

Full Name: *

Address: *

Email: *

Phone: *

Details - 2

Full Name: *

Address: *

Email: *

Phone: *

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Authentication from Regional MS Society

Please have your local MS Community Advisor fill in the information below as confirmation of your identity and diagnosis of MS along with a letter of support.
If you are not a member of the Regional MS Society, please have your local GP complete the details instead along with a letter of support.

Name: *

Position: *

Regional MS Society/Region: *

Signature *

Clear Signature

Date *

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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.
I have attached a letter of support from MSNZ or an MS Regional Society.
I confirm that the nominee has not been made aware of this application.
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.
I confirm that I am happy to be contacted if more information is required by MSNZ or the Award Committee.
I agree to the Conditions of Entry as detailed on the Criteria.

Signature *

Clear Signature

Date: *

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Esme Tombleson Award Nomination Application Form