Nomination Form

NOMINATIONS CLOSE FEBRUARY 15, 2022 FOR THE 2021 CALENDAR YEAR.

Instructions: Complete all information below. Provide detailed support documentation (reports, news articles, photo and video content, interviews, social media links, other) to assist the validation of the incident, eligibility of the nominee/team, and level of Award nomination. Statements/affidavits should contain details and facts that clearly show the manner and extent of extraordinary effort. Provide 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. VALIDATE WITH YOUR AGENCY PERMISSION TO SUBMIT NOMINATION (some have specific guidelines that must be followed).

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):












    Nominator has informed individual(s), team, agency or organization and been granted authorization to submit award nomination.
    YesNo

    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 create a shared folder at dropbox.com, upload attachments to that 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.