Certificate of Recognition Request Form
Our office is happy to recognize members of our community! 

Certificates of Recognition from Assemblymember Josh Lowenthal can be provided to individuals or organizations who have had a positive impact in the 69th Assembly District. 
** Note that requests are not guaranteed

If you have any further questions or concerns, please feel free to reach out to our office at 562-429-0470. You may also reach out to our field representatives at jeanie.le@asm.ca.gov, lizeth.chimal@asm.ca.gov, or clayton.heard@asm.ca.gov. 
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Contact Info
Contact full name *
Contact Email *
Contact Cell Number *
Organization (if applicable) 
Certificate Information
Who/ what is being recognized? *
If multiple, please list and number
Organization Recognizing the Honoree (if applicable)
 *
** Ex. The X Organization is awarding Person A for Person of the Year
Please be specific and include what organization, company, regional chapter, etc. if applicable
What are they being recognized for? What are some accomplishments? Please list at least 3 line items and be specific *
Certificate Presentation Event Details 
Event Description
Ex. Grand Opening, Graduation, Award Ceremony
Date of Event
MM
/
DD
/
YYYY
Time of Event
Time
:
Time of Certificate Presentation
Time
:
Location of Event
Additional questions or comments
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