Awards Nomination Form .pdf
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3rdAnnual Awards
2017 NOMINATION FORM
DEADLINE: Wednesday, April 12, 2017
Please complete all information:
NOMINEE (person or group being nominated – Please list one person as main contact as well as group name if applicable:
First Name: __________________________________
Last Name: __________________________________________
Group Name: If applicable ______________________________________________________________________
Email: _______________________________________ School (if applicable): _____________________________________
Street: _______________________________________ City: _____________________ Postal Code: ________________
Daytime ph#: __________________________
Cell phone #: _____________________
If NOMINEE is under 18, please complete the following:
Nominee’s Grade level: ________________School (mandatory):______________________________________________
Nominee’s parent(s)/guardian(s) name(s): _______________________________________________________________
Email: ________________________________________
If different from above
Street: _____________________________________
P.C.: ________________
Home ph#: ___________________________
City: ____________________________
Daytime ph #: ____________________
NOMINATOR (person/organization submitting the nomination):
First Name: __________________________________
Last Name: __________________________________________
Email: _______________________________________ School (if applicable): _____________________________________
Street: _______________________________________ City: ________________________________________________
P.C.: _________________
Daytime#: ___________________________
Have you notified the Nominee? (mandatory):
□
Yes
□
Cell Phone #: ____________________
No
AWARD CATEGORIES:
□
□
Fire
Police
□
□
EMS
Education
□
□
Community Service
Environment
Mar. 29, 17

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