FLORIDA STATE FRATERNAL ORDER OF POLICE-TALLAHASSEE, FL

GOVERNOR'S MEDAL OF HEROISM NOMINATIONS
Pursuant to Florida State Statute Section 112.194

You may submit this nomination electronically or print this page and snail mail to the address below. A 500 word or less synopsis should accompany this nomination.

Criteria for Nomination: (Must Meet All Four Components)

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:
Medal of Heroism Selection Committee
PO Box 1349
Tallahassee, FL 32302

Last Name	First Name	Middle


Street Address	City	State


Zip Code	Email Address


Maritial Status	Date of Birth
	/ /


Agency Employed By
Position Held
Agency Size (Number of Certified Personnel)
Agency Head

Length of Time Employed by Agency
1 - 2 yrs	3 - 5 yrs	> 5 yrs

Address	City	State


Zip Code	Agency Phone


Attach your 500 word or less synopsis (.txt , .doc, .pdf)


Upper torso and face photograph (optional)


Other Public Safety Experience (optional)


Required Field