Nomination Form

Please fill in the form below. Alternatively you can download the nomination form and return it to Jane Taylor or Alison Fletcher, from the South Yorkshire Police organising team.

Nominee

First name: *

Surname: *

Age at time of incident: *

Date of birth: *

Address: *

Home telephone number:

Mobile telephone number:

Email:

Force

Forces are required to nominate a single point of contact for all nominations. The SPOC will be responsible for all liaison with the South Yorkshire Police organising team and the nominee, including making arrangements for:

the attendance of a member of their command team
the attendance of a Police authority member
liaison with OICs
travel arrangements for award winners
local presentation for certificate winners

Nominating force: *

Single point of contact: *

Rank / Position: *

Contact telephone: *

Email address: *

Postal address: *

Circumstances

(Please provide as much information and supporting evidence as possible e.g. press cuttings. Please see example nomination.)

Time:

Day:

Date:

Location

Road:

Town:

County:

Details:

Outcome of Case

Court or investigation result:

Trial date if sub judice:

Other offenders sought?:

Other awards made?:

Other people involved in this incident? Outcome::