Your Name: ________________________________ Phone #: __________________
Please answer as much of the following as you are able to and feel free to use the back side for more space. Make copies if more than one nomination is submitted.
Name of person you would like to Nominate: ___________________________________
Nominees contact information :
Address: ____________________________ Phone #: __________________
City, State, Zip: ________________________________________________________
Date of incident : ___________________________________________________________
Place of incident: ___________________________________________________________
Other persons involved in incident : ___________________________________________
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Description of incident: _____________________________________________________
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Please
attach any other information you have (i.e.: newspaper
articles, police/fire reports, accident reports, etc.) and mail
to:
Safety Council of Northwest Ohio
Attn: Hero Selection Committee
8015 Rinker Pointe Court , Northwood , Ohio 43619