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Award Nomination Form

2. Date Submitted*
   Date Submitted

3. Name of person submitting nomination*

5. Submission for:*

   1. Fire Service
   2. Police
   3. Civilian
   4. Other (i.e. other city department, etc.)

6. Employee or EPD Officer name, rank and badge number if pertinent to the award

8. Shift on Duty

   1. 1st
   2. 2nd
   3. 3rd

9. Stations that responded

   1. Station 1
   2. Station 2
   3. Station 3
   4. Station 4
   5. Station 5
   6. Station 6
   7. Station 7

11. Date of incident*
    Date of incident

12. Alarm number if applicable

14. Please list the names of all nominees*

    If a crew award please ensure all personnel that responded on the call are listed.

16. Please provide all pertinent contact information for civilian award nominees

18. Please provide a very detailed description of the incident and the actions taken to warrant the recognition*

20. Please submit additional documentation (i.e. newspaper articles, letters, witness statements, etc.) to Awardscommittee@cityofelgin.org

22. Please cc' this form to the Staff Officers assigned to the shift on which the incident occurred.

Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

* indicates a required field