2. Public Recognitions Request

4. Please reference the requirements for each award in the Public Recognition Policy here.

8. Please select the recognition that you are requesting:*

   1. Pins and Medals
   2. Community Leader Award of Distinction
   3. Wall of Honor
   4. Memorial, Monument and/or Facility Naming
10. Please list your preferred City Council meeting date(s) for the recognition requested and any other related details.
14. Requestor Information

    For the following recognitions, the requestor must be different from the recipient as this will be considered as a nomination: Community Leader Award of Distinction, Wall of Honor, Memorial, Monument and/or Facility Naming

16. Requestor First and Last Name*
17. Organization (If Applicable)/ Relationship to Nominee
19. Requestor Phone Number*
20. Requestor Email Address*
22. Requestor Address*
24. City*
25. State*
26. Zip Code*
30. Nominee Information
32. Nominee First and Last Name *
33. Organization (If Applicable)
35. Nominee Phone Number*
36. Nominee Email Address*
38. Nominee Address*
40. City*
41. State*
42. Zip Code*
46. Please explain in detail the reason you are making this request and why you would like the Council to consider this recognition:*
50. Impact Statement

    Please see the Public Recognition Policy here for additional details. 

    For the following awards listed below, please complete the Impact Statement in its entirety:

    Community Leader Award of Distinction

    Wall of Honor

    Memorial, Monument and/or Facility Naming 

    
    

    IMPACT STATEMENT

    • Resume - Please demonstrate proof of impact of the nominee to the community with dates of service included in the resume. 
    • Letter(s) of Recommendation
    • Additional Documentation - Opportunity to further support the nominee's impact on the community

    Period of time as well as contributions recognized by a significant segment of the community and their respective industry (education, nonprofit, business) will be considered upon review of request.  

52. Resume of Nominee*
54. Letter(s) of Recommendation*
56. Additional Documentation
58. Any Additional Comments?
60. Electronic Signature Agreement*

    1. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
62. Electronic Signature*

64. After submitting this form, you will be contacted shortly regarding the status for your request.

    Thank you!

Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit

* indicates a required field