THE AMERICAN LEGION
DEPARTMENT OF PENNSYLVANIA
NOMINATION FORM
FOR
PENNSYLVANIA FIREFIGHTER OF THE YEAR
NAME__________________________________________________ MALE______ FEMALE _____ RANK _________________
HOME ADDRESS ___________________________________________________________________________________________
CITY/STATE/ZIP___________________________________________________________________________________________
MARITAL STATUS ____________________ SPOUSE'S NAME ___________________________________________________
FIREFIGHTERS AGE ___________________
LENGTH OF SERVICE ______________YEARS
(CHECK ALL THAT APPLY)
ST
CAREER ______ VOLUNTEER ______ 1
RESPONDER ______ EMT ______ PARAMEDIC I ______ II ______
LOCAL UNION __________YES __________NO
NUMBER________________________________________________
FIRE DEPARTMENT NAME_________________________________________________________________________________
_____________________________________________________________________
DEPARTMENT ADDRESS
CITY/STATE/ZIP___________________________________________________________________________________________
FIRE CHIEF'S NAME _______________________________________________________________________________________
IMMEDIATE SUPERVISOR’S NAME _________________________________________________________________________
DEPARTMENT PHONE NUMBER ____________________________________________________________________________
STATION PHONE NUMBER _________________________________________________________________________________
INDIVIDUAL SUBMITTING NOMINATION __________________________________________________________________
POST NO.__________ DISTRICT NO. __________ PHONE NUMBER ______________________________________________
POST ADDRESS____________________________________________________________________________________________
____________________________________________________
CITY/STATE/ZIP_____________________________
BE SURE TO ATTACH ALL SUPPORTING INFORMATION REQUESTED INCLUDING: BIOGRAPHY, DETAILED WORK
HISTORY, CERTIFICATES EARNED, AWARDS RECEIVED, SPECIAL ACTS OF HEROISM, COPIES OF NEWSPAPER
CLIPPINGS (IF AVAILABLE) AND ANY OTHER PERTINENT INFORMATION. IF THE NOMINEE IS A VETERAN OF THE U.S.
MILITARY, A COPY OF THEIR DD-214 OR HONORABLE DISCHARGE MUST BE INCLUDED.
RETURN TO:
THE PA AMERICAN LEGION
PO BOX 2324
HARRISBURG, PA 17105
DEADLINE DATE: JANUARY 4, 2016