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GOVERNOR'S MEDAL OF HEROISM NOMINATION FORM

Established by Florida State Statute 112.194

You may submit this nomination electronically by clicking below, or print this page and mail it to FPCA Headquarters at the address below. A synopsis of the act(s) of heroism (500 words or less ) must accompany this nomination form.

Criteria for Nomination: (Must meet all four requirements.)

    1. Nominee must have risked his/her life.

    2. Nominee must have known there was perilous risk.

    3. Nominee performed in the capacity of his/her position.

    4. Nominee's actions were for the express purpose of saving a life.

To mail your nomination, use the address below:

    Florida Police Chiefs Association
    Medal of Heroism Nomination
    Awards Committee
    P.O. Box 14038
    Tallahassee, FL 32317
   
Nominee Information:
Last Name First Name Middle
     
Street Address City State
     
Zip Code Email Address  
 
     
Maritial Status Date of Birth  
//  
     
Agency  
Position  
Agency Size (# certified personnel)  
Agency Head  
 
Years of Service
1 - 2 yrs 3 - 5 yrs 5 yrs or more
 
Address City State
 
Zip Code Agency Phone  
 
 
Synopsis
     
Your name:
     
Your phone:
     
Your E-mail:

Press the Submit button and your nomination will be forwarded electronically.

Questions? Contact the FPCA @ 1-800-332-8117 for information.

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