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Fred L. Burns Community Service Award

2. Fred L. Burns Community Service Award Nomination Form

   Nomination period is midnight of January 1st to midnight of December 31st. Please use this form to nominate an exemplary individual for the Fred L. Burns Service Award. Nominees must be someone who has made a significant contribution to the Chino Valley Fire District in the area of furthering the District’s Mission Statement and who has made a significant contribution to the Chino Valley. The Mission of the Chino Valley Independent Fire District is to protect the lives and property of the community from the detrimental effects of fires, medical emergencies and other hazardous conditions.

   Nomination period is midnight of January 1st to midnight of December 31st. Please use this form to nominate an exemplary individual for the Fred L. Burns Service Award. Nominees must be someone who has made a significant contribution to the Chino Valley Fire District in the area of furthering the District’s Mission Statement and who has made a significant contribution to the Chino Valley. The Mission of the Chino Valley Independent Fire District is to protect the lives and property of the community from the detrimental effects of fires, medical emergencies and other hazardous conditions.

4. Please Check One:

   1. Mr.
   2. Mrs.
   3. Ms.

5. Nominee's First Name

6. Last Name

8. Address

10. City

11. State

12. Zip

14. Home Phone

15. Cell Phone

16. Email

18. Please Check One

    1. Mr.
    2. Mrs.
    3. Ms.

19. Nominator's First Name

20. Last Name

22. Organization

    (If applicable)

24. Address

26. City

27. State

28. Zip

30. Home Phone

31. Cell Phone

32. Email

34. Date
    Date

    Date

36. Relationship to Nominee

38. How did you become familiar with the nominee's volunteer work

40. Years of volunteerism or community service

42. References

    Please provide two references who are familiar with and can verify the scope and extent of the nominee's volunteer service activities. These people may not be the nominator, nominee, or a relative of the nominee. Please make the individuals aware they may be contacted.

    Please provide two references who are familiar with and can verify the scope and extent of the nominee's volunteer service activities. These people may not be the nominator, nominee, or a relative of the nominee. Please make the individuals aware they may be contacted.

44. Reference #1

46. First Name

47. Last Name

49. Home Phone

50. Cell Phone

51. Email

53. Reference #2

56. First Name

57. Last Name

59. Home Phone

60. Cell Phone

61. Email

63. Nominations will be evaluated based on your answers to the questions below. Please be specific and detailed. All responses should be 500 characters of less

65. 1. Please describe how your nominee helped further the Fire District's Mission statement and made a significant contribution to the Chino Valley Community

67. 2. How has the work of the nominee improved the community or enhanced the lives of its residents for which/whom the work was performed

69. 3. Please describe how your nominee exhibits the spirit of the Fred L. Burns Service Award

71. If the nominee's service was performed as a volunteer for a specific organization or group, please provide a name, address, telephone number and contact person for that group

73. Please provide any additional comments you feel will help in the selection process

Leave This Blank:


74. 1. Receive an email copy of this form.
75. Email address

    This field is not part of the form submission.

76. Submit

* indicates a required field