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The nomination period is from 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 Chino Valley Fire 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.
Nominee's Information
Please provide contact information for the person you are nominating.
First Name*
Last Name*
Street Address*
Apartment / Unit / Space
City*
State*
Zip Code*
Nominee's Home Phone
Nominee's Cell Phone
Email Address*
Nominator's Information
Please provide your contact information.
First Name*
Last Name*
Orgaization / Business Name
Address*
Apartment / Unit / Space
City*
State*
Zip Code*
Nominator's Home Phone
Nominator's Cell Phone
Nominator's Business Phone
Nominator's Email Address
What's your relationship to the nominee?*
Date of Nomination*
Date of Nomination
How did you become familiar with the nominee's volunteer work?*
How many years of volunteerism or community service has the nominee performed?
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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.
Reference # 1
First Name*
Last Name*
Home Phone
Cell Phone
Email Address
Reference #2
First Name*
Last Name*
Home Phone
Cell Phone
Email Address
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The nomination period is from 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 Chino Valley Fire 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 Questions
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.
Question 1: Please describe how your nominee helped further the Fire District's Mission statement and made a significant contribution to the Chino Valley Community.*
Question 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?*
Question 3: Please describe how your nominee exhibits the spirit of the Fred L. Burns Service Award.*
Question 4: 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.*
Question 5: Please provide any additional comments you feel will help in the selection process.*

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