Fleet Safety Awards 2018: Outstanding Commitment Award entry form

Thank you for your interest in entering Brake’s Fleet Safety Awards. Please read the terms and conditions and instructionscarefullyand fill out the requested details below.

Terms and conditions

1.Entries must be submitted by email to Friday 29 June 2018. You will receive an email confirming receipt of your entry. If you do not receive an email acknowledging your submission within two working days, please contact +64 (0)21407953.

2.If you are unable to use this form to submit your entry, please contact fore the deadline to arrange an alternative submission.

3.If you are entering the awards, you will be invited to attend the Fleet Safety Awards reception on Thursday 11 October 2018 in Auckland, New Zealand.

4.Entries must include a copy of the entering organisation’s logo.

Instructions

  1. Please read the ‘Guidance notes for entrants’ document before completing your entry.
  2. You may enter as many award categories as you like but will need to submit a separate entry form for each award you enter.
  3. Please complete all fields in the entry form below.
  4. Please note that as each category is judged separately, you will need to provide all relevant details for each award you enter. Please do not enter text such as “see award X submission for further details” as our judges will only see the information you have submitted for that particular category.
  5. If you wish to provide any supporting evidence for your entries (e.g. internal reports, documentation or guidance), please submit that along with your award entry form(s) in line with the specific requirements outlined in the ‘Guidance notes for entrants’ form.

Outstanding Commitment to RoadSafety Award

Please provide the contact details of the person submitting the entry
Name
Job title
Telephone number
Email
About your organisation
Organisation/company name:
Is your organisation (pick one): / Private sector - Other Please specify
Is your organisation (pick one): / A fleet operator - Other Please specify
How big is your vehicle fleet?
Please enter approximate numbers for each vehicle type. If you do not operate a vehicle fleet, please enter 0 in each box. / Cars 0
Vans 0
Trucks 0
Buses/coaches 0
Motorcycles 0
Other vehicles 0
About your entry
Are you a Brake Professional member? / Yes /
How did you hear about this year’s Awards?
(tick one) / Email from Brake☐
Phone call from Brake☐
Email from another source☐
Read in Vision Zero☐
Brake website☐
Social media ☐
Other website☐
Press/media☐
From a colleague☐
Other (please state) - Other
Is this the first time you have entered the Fleet Safety Awards? / Yes /
Outstanding Commitment to Road Safety Award
Please note that you cannot nominate yourself for this Award: nominations must come from someone else within the industry.
Nominee name
Job title
Organisation (if applicable)
Individual role and commitment
Explain how this individual has demonstrated a sustained commitment to road safety over a number of years, and how they have been a driving force behind road safety initiatives within their role/organisation and/or externally. How have they gone above and beyond the requirements of their role(s) to have a lasting impact on road safety?
(max 600 words)
Additional information
If you would like to include supporting evidence for your entry (e.g. internal reports, documentation or guidance), please attach as a single PDF file to your entry email.This will be sent to all judges alongside your category entries.
Additional supporting information must be limited to a maximum of 2 sides of A4 per Awards category entered.
This information must clearly indicate your organisation name and the award entry for which the additional information supports.
Any information provided that does not meet the requirements of this form and the guidance listed within the guidance notes for entrants documentwill not be considered as part of your entry. / Please tick if you are submitting additional information to support this award entry ☐
Company logo
Please attach a copy of your company logo (saved as a JPEG file) along with your submission. /
I confirm a logo has been attached along with our submission ☐
Photograph
Please attach a head and shoulders photo of the individual when you submit your entry. Please include the name of the individual in the file name and attach as a separate file. / I confirm a photo has been attached along with our submission ☐

Thank you for completing this form. Please read back over carefully and ensure you have completed all fields before submitting.

By submitting this form you are agreeing to the terms and conditions (above).