Nomination - Individual

For O40s & O50s - Must be submitted by 27th April 2012. For 045s & O55s - Must be submitted by 1st  June 2012   LEGEND Please note the asterisk beside the boxes down the form relate to the following information .   * Nominating For: Tick one only - submit a separate form for each age division you are nominating for. (Eligibilty: eg. for 40+ must have turned 40 by 31 Dec 2012. For 45+ must have turned 45 by 31 December 2012 etc)   ** 2012 State Championships Playing Particulars - This is for the State Championships indicating which team you are playing for and preferred team position. *** Please list major achievements and particulars of your recent playing career (indicate year selected)   **** I have read and understood the 'Hockey Queensland Nomination Details' form as supplied by my Association and I agree to the condition of selection etc determined by Hockey Queensland. Tick the 'Yes I agree' box or 'No I don't agree' box marked with ****       Team You Are Nominating For Name Date Of Birth Address Home Ph: Work Ph: Fax: Mobile: Email: *O35+ Team <1> *O40+ Team <1> *O45+ Team <1> *O50+ Team <1> *O55+ Team <1> *O60+ Team <1> *O65+ Team <1> *O70+ Team <1> ** Team Playing For ** Championships Attending - S Coast <1> ** Championships Attending - Cairns <1> ** Preferred Position 1 ** Preferred Position 2 ** Preferred Position 3 ** Preferred Position 4 *** Achievements - Australian Team/Squad *** State Team/Squad *** City or Association *** Current Club, Team & Grade *** Major Awards Won **** Terms - Yes, I Agree <1> **** Terms - No, I Don't Agree <1>