Public Service Award Nomination Form

Thank you for nominating someone to receive San Rafael's Public Service Award! While completing this nomination form, please provide as much information as possible to allow the selection committee to make the most informed decision possible. The selection committee may not know the person you are nominating, so please be descriptive in your answers.
Date * Required
MM slash DD slash YYYY
Nominee for Public Service Award * Required
First Last
Nominee's Home Address * Required
Street Address Address Line 2 City ZIP / Postal Code
Does this nominee live within San Rafael City Limits? * Required
- Yes
- No
Nominee's Phone
Nominee's Email
Your Name * Required
First Last
Your Address * Required
Street Address Address Line 2 City ZIP / Postal Code
Your Phone * Required
Your Email * Required
When answering the questions below, please provide as much information as possible to allow the selection committee to make the most informed decision possible. The selection committee may not know the person you are nominating, so please be descriptive in your answers.
What contributions has this individual made to the community that are beyond the scope of normal civic responsibilities? * Required
What impact on the community did this individual's activities make? How has this person made a difference? * Required
Discuss the time and energy this person has devoted to community projects or efforts. * Required
Discuss the challenges met and overcome by this individual. * Required
To what extent has this individual's efforts been previously recognized by the community? * Required
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Public Service Award Nomination Form