NominationForm SafetyAward
ATSSA 2017 National Safety Award Nomination Form Over the past 28 years, the members of ATSSA have honored and recognized public officials with the prestigious National Safety Award. To nominate an individual, please fill out this form below and submit it to ATSSA by August 4, 2017. I would like to nominate: __________________________________ Title ____________________________________ Government Agency __________________________________________________________ for the ATSSA 2017 National Safety Award. This person is employed by a government agency (or retired from a government agency after August 4, 2015), and has made a significant contribution to the safety of our nation’s highways. Nominee’s Current Address: ____________________________________________________ City ______________________________ State __________________ Zip _______________ Phone______________________ Email ___________________________________________ Please answer the following questions about the person you are nominating for this award (attach additional sheet(s) if necessary). 1. What contributions has the nominee made to roadway safety? Be specific and include the dates when each contribution occurred.
Nomination Form: ATSSA National Safety Award
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2. How has the nominee’s contribution(s) improved traffic safety regionally and/or nationally?
3. Is there anything else ATSSA should know about the nominee, such as involvement with ATSSA, our chapters, or in other traffic safety organizations?
Name of Person Making Nomination: ____________________________________________________ Phone __________________ Company____________________________________________ Date ___________________ Submit this form to ATSSA at [email protected] or fax to 540-368-1717 by the August 4, 2017 nomination deadline.
Email Form
Nomination Form: ATSSA National Safety Award
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Nomination Form: ATSSA National Safety Award
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2. How has the nominee’s contribution(s) improved traffic safety regionally and/or nationally?
3. Is there anything else ATSSA should know about the nominee, such as involvement with ATSSA, our chapters, or in other traffic safety organizations?
Name of Person Making Nomination: ____________________________________________________ Phone __________________ Company____________________________________________ Date ___________________ Submit this form to ATSSA at [email protected] or fax to 540-368-1717 by the August 4, 2017 nomination deadline.
Email Form
Nomination Form: ATSSA National Safety Award
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