Lifesaving Award Nomination Form

LIFESAVING AWARD
Nomination Form
Deadline for submission: April 15th
ELIGIBILITY: All sworn, full-time Florida Police Officers, below the rank of Chief, of FPCA member agencies are eligible. Nominations may be made for an exceptional lifesaving act that places the officer’s life in jeopardy.
Nominee's Rank*
Nominee's Name*
First Last
Department/Agency*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Nominee's Email*
Dates of Employment In Current Position*
Section II - Nominator Information
Nominator's Rank*
Nominator's Name*
First Last
Organization*
Phone*
Email*
Please describe the exceptional lifesaving act. In addition provide documentation of the incident such as a police report.*
Attach documentation here.
Date(s) of Exceptional Act(s)*
Agency Head Signature*
Date*
Date Format: MM slash DD slash YYYY

LIFESAVING AWARD