Form Il 493-1241-Isp 2-388-Illinois Law Enforcement Medal Of Honor Nomination Form
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12015 NOMINATION
Illinois Law Enforcement
MEDAL OF HONOR
Nomination Form
CRITERIA: In accordance with Public Act 86-1230, “The Law Enforcement Medal of Honor Committee may award, and pres-
ent a medal of honor of appropriate design, with ribbons and appurtenances, to law enforcement officers who have been
killed or seriously injured in the line of duty or who have displayed exceptional bravery or heroism while performing their
duties as a law enforcement officer.”
Full Name, Rank and Address of Nominee:
Last Name: _____________________________________________________
Home Address (Required): _____________________________________
First Name: _____________________________________________________
City, State, Zip ____________________________________________
____________________
Phonetic Spelling: (Last) __________________ (First) _________________
Home Phone: (
)
Middle Initial: _________
Rank: ____________________________________
(If no middle initial - please indicate NMI)
Reason(s) for Nomination:
Brief Synopsis:
(Attach supporting documentation justifying nomination, limited to two typewritten pages. May include police reports and
news clippings.)
Was there media coverage of the event?
Date of Occurrence: _________________________________
(Extraordinary police work MUST have occurred in calendar year 2015.)
Yes
No
Person Submitting Nomination (Chief or Head of Agency ONLY)
Name: ____________________________________________________Rank: ________________
Department: _____________________________________________________________________
Address: ________________________________________________________________________
City _____________________________________________________ State _____________ Zip __________________
_________________________________
Telephone Number: (
)
PLEASE NOTE: A 3x5 head and shoulders photo of each nominee must be included. Submissions will not be returned. All
completed nomination forms must be forwarded by February 26, 2016, to:
Illinois State Police
Office of Human Resources - Awards Program
801 South Seventh Street, Suite 1001-A
Springfield, IL 62703-2487
Telephone: (217) 557-1672
FAX: (217) 524-0222
TDD (800) 255-3323
IL 493-1241
ISP 2-388 (1/16)
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