2020-2021 CT100 Award Nomination Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This form is used to nominate First Responders for exceptional achievement, as well as lifetime service, in any police, firefighting or emergency medical endeavor. Nominees should be someone who represents a department/agency with honor and extols the highest standards within the community. All First Responders covered by the Chisholm Trail 100 Club* are eligible to win these awards. Nominations may be submitted by peers, supervisors and/or community members. Submitted nominations are then reviewed by the Chisholm Trail 100 Club's Awards Committee. Awards are not intended to be given every year, and may not be awarded even if nominations have been made.

*Chisholm Trail 100 Club's service area includes: Johnson, Somervell and Hood Counties and the City of Mansfield.

Email *

Nominator's Name: *

Nominator's Work/Cell Phone: *

Nominator's Relationship to Nominee: *

If "Other" indicated in previous question, please describe relationship to nominee:

Award Category: *

Which award are you nominating the individual? NOTE: NOTE: All nominees must be active or retired first responders from Johnson, Somerville, or Hood County, or the City of Mansfield.

Chisholm Trail 100 Club Award - This award acknowledges first responders for outstanding bravery and/or extraordinary actions performed in the line of duty. Nominations may include department and community testimonials, commendations and relevant media articles. The award includes recognition and $500 cash.

Lifetime Achievement Award - This award acknowledges first responders who have completed 20 years or more of distinguished service and who have made a positive impact in their community. Nominations must include department and community testimonials, commendations and relevant media articles. The award includes recognition and a commemorative gift.

Nominee's Name *

Include rank, first name, last name

Nominee's Agency/Department: *

Nominee's Supervisor/Dept Head Name: *

Nominee's Supervisor/Dept Head Phone Number: (NOTE: If unknown, enter N/A) *

Nominee's Supervisor/Department Head Email: (NOTE: If unknown, indicate N/A)

Please describe in detail information regarding the incident/service for which the individual is being nominated. For the CT100 Award, include at a minimum 1) date of incident; 2) type of extraordinary service provided; 3) circumstances of the incident. For the Lifetime Achievement Award, include at a minimum 1) dates of service; 2) agency(s)/department(s) served; 3) department and community testimonials, 4) commendations and 5) relevant media articles. *

If you need additional space and/or would like to submit a pdf/doc file providing details, please email cara@ct100.org, News articles, portions of 9-11 transcript, department and community testimonials, etc, may also be submitted via email.

Do you have a photo of the nominee that can be submitted if they are selected as a recipient? *

Yes

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Chisholm Trail 100. Report Abuse

Forms