NWZMemorial NameSubmission
The National Work Zone Memorial Name Submission Form Unveiled in April 2002, The National Work Zone Memorial is a living tribute to the memory of lives lost in work zones. The Memorial travels to communities cross-country, year-round to raise public awareness of the need to respect and stay safe in America’s roadway work zones. 1. 2. 3. 4.
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Name of Deceased: ___________________________________________________________________ Date of Fatality: _____________________________________________________________________ Location of Fatality (City and State): ______________________________________________________ The Person Named Above (Fatality Must Have Occurred in a Roadway Work Zone): Child Pedestrian Law Enforcement Public Safety Official Motorist Work Zone Worker Brief Description of Work Zone Accident: _______________________________________________ Verification of above is provided in the form of (please provide all available): Official police accident report Notarized employer affidavit (applicable in case of roadway workers, law enforcement officers, and emergency workers only) Newspaper or media clipping Please email or mail a high-resolution photo of the person named above. Does the person named above have dependents (children and/or spouse)? ____________________ _________________________________________________________________________________ If yes, please include family contact information. The Foundation has resources for families - The Roadway Worker Memorial Scholarship program (post-high school education scholarship) and the Experience Camps Travel Scholarship program (summer camps for grieving children). Family Member Contact Name: _______________________________________________________ Street Address: ____________________________________________________________________ City: _____________________________________ State: ____________________Zip: ___________ Email address: ______________________________ Phone:_________________________________ I certify I have obtained permission from the deceased’s family or former guardian to provide the above information, and for the deceased’s name to be listed on the National Work Zone Memorial. By providing this information, applicant shall indemnify and save and hold harmless American Traffic Safety Services Association (ATSSA), American Traffic Safety Services Foundation (The Foundation) and its officers, agents, and employees acting for ATSSA or The Foundation, against any liability, including costs and expenses. I further certify that all information provided is true and correct to the best of my knowledge. For motorist category only: I further certify that the individual named on this form was not under the influence of drugs or alcohol at the time of the fatality.
Signature of Applicant: _________________________________ Date of Application: _______________ Name of Applicant: ____________________________________________________________________ Organization (if applicable): _____________________________________________________________ Email address: _________________________________ Phone:_________________________________ *Instructions: Complete this form, include required documentation (item 6 above), and mail to American Traffic Safety Services Foundation, 15 Riverside Parkway, Suite 100, Fredericksburg, VA 22406 or fax to 540-368-1717, Attn: Lori Diaz, or email [email protected]. **Names submitted before December 1, 2017 will be included on the Memorial Exhibition in 2018. ©American Traffic Safety Services Foundation
Name Submission 2017
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Name of Deceased: ___________________________________________________________________ Date of Fatality: _____________________________________________________________________ Location of Fatality (City and State): ______________________________________________________ The Person Named Above (Fatality Must Have Occurred in a Roadway Work Zone): Child Pedestrian Law Enforcement Public Safety Official Motorist Work Zone Worker Brief Description of Work Zone Accident: _______________________________________________ Verification of above is provided in the form of (please provide all available): Official police accident report Notarized employer affidavit (applicable in case of roadway workers, law enforcement officers, and emergency workers only) Newspaper or media clipping Please email or mail a high-resolution photo of the person named above. Does the person named above have dependents (children and/or spouse)? ____________________ _________________________________________________________________________________ If yes, please include family contact information. The Foundation has resources for families - The Roadway Worker Memorial Scholarship program (post-high school education scholarship) and the Experience Camps Travel Scholarship program (summer camps for grieving children). Family Member Contact Name: _______________________________________________________ Street Address: ____________________________________________________________________ City: _____________________________________ State: ____________________Zip: ___________ Email address: ______________________________ Phone:_________________________________ I certify I have obtained permission from the deceased’s family or former guardian to provide the above information, and for the deceased’s name to be listed on the National Work Zone Memorial. By providing this information, applicant shall indemnify and save and hold harmless American Traffic Safety Services Association (ATSSA), American Traffic Safety Services Foundation (The Foundation) and its officers, agents, and employees acting for ATSSA or The Foundation, against any liability, including costs and expenses. I further certify that all information provided is true and correct to the best of my knowledge. For motorist category only: I further certify that the individual named on this form was not under the influence of drugs or alcohol at the time of the fatality.
Signature of Applicant: _________________________________ Date of Application: _______________ Name of Applicant: ____________________________________________________________________ Organization (if applicable): _____________________________________________________________ Email address: _________________________________ Phone:_________________________________ *Instructions: Complete this form, include required documentation (item 6 above), and mail to American Traffic Safety Services Foundation, 15 Riverside Parkway, Suite 100, Fredericksburg, VA 22406 or fax to 540-368-1717, Attn: Lori Diaz, or email [email protected]. **Names submitted before December 1, 2017 will be included on the Memorial Exhibition in 2018. ©American Traffic Safety Services Foundation
Name Submission 2017
