Applicant Information

Please fill out the following form in its entirety. All departments submitting nomination forms must have had their program up and running for at least one year.

Departments can not be selected to win more than 2 times in a 5-year period.

All forms MUST be submitted by Friday, July 23, 2014

Question Title

* 1. Agency being nominated:

Question Title

* 2. Nominator's name and title:

Question Title

* 3. Contact Address: provide address, city, zip.

Question Title

* 4. Phone:

Question Title

* 5. Fax:

Question Title

* 6. E-mail:

Question Title

* 7. Date of implementation of wellness/fitness program or project: *minimum 1 year prior to nomination

Question Title

* 8. Category applying for

Question Title

* 9. Total number of personnel:

Question Title

* 10. Number of full-time:

Question Title

* 11. Number of part-time:

Question Title

* 12. Number of reserve:

Question Title

* 13. Number of volunteer:

Question Title

* 14. Name of Fire Chief or Executive Officer

Question Title

* 15. Fire Chief or Executive Officer phone number:

Question Title

* 16. Fire Chief or Executive Officer email:

T