2017 Nomination Form

Instructions: Complete all information below. Be as specific and detailed as possible. Provide as many attachments as required to assist the validation of the incident, eligibility of the nominee/team, and level of Award nomination. Statements/Affidavits should contain as much detail as the party can recall including all facts and occurrences to clearly show what manner and to what extent an extraordinary effort was made, witness names, persons rendering assistance during the incident and all pertinent circumstances and data showing the precise nature and level of competence involved. Additional information/attachments should be emailed to nominations@higginsandlangley.org.

Before filling out this form please carefully read the awards criteria. If you’d prefer to print out the form and send it in, you may download it in PDF format.

If selected for an award, the primary point of contact (Submitting Official/Chief/Commander below) will be notified by H and L Board of Directors.  It is the responsibility of the NOMINATOR to contact all other representatives.

Submitting Official/Chief/Commander (PRIMARY CONTACT/NOMINATOR):












A nomination is submitted for the following category:
IncidentSpecial CommendationProgram DevelopmentOutstanding AchievementLifetime Achievement

Type of nominee:
IndividualMultiple IndividualsTeamMultiple Teams

Type of duty:
Paid full-time ProfessionalPaid part-time ProfessionalUnpaid/Volunteer ProfessionalCombination (individuals)Combination (teams)

Date/Period being recognized:

Nominee or Primary POC: (additional nominees, parties, team members listed below as needed; all information shall be included for every listing)













Relevant Attachments: Attach all credible supporting documentation (maximum file size is 1mb. Audio/Video clips will exceed this limit, so you may alternatively upload attachments to a dropbox.com folder and share the folder with nominations@higginsandlangley.org)

I will be sending additional attachments via email: nominations@higginsandlangley.org or dropbox.com

Complete/Detailed Summary of Incident
Nominee statement
Newspaper Articles
Police/Fire/Rescue Reports
Witness Accounts
On-Scene Commander Report
State/Provincial Agency Reports
Copy of certification(s)
Federal Agency Reports
Other Recognition (nominated or received)
ICS Reports
Affidavit(s)
Other Attachment

Note: You'll need to fill out a separate block for each nominee or team member. Unlisted nominees cannot be considered!

ADD ADDITIONAL NOMINEES noyes

1) Additional Nominee/Team Member:












2) Additional Nominee/Team Member:












3) Additional Nominee/Team Member:












4) Additional Nominee/Team Member:












5) Additional Nominee/Team Member:












6) Additional Nominee/Team Member:












7) Additional Nominee/Team Member:












8) Additional Nominee/Team Member:












Do you have more than eight additional nominees? Please email their detailed information to nominations@higginsandlangley.org. Note the Nomination Year and Name of Incident/Program in your email.