Gulf Coast State College | Hall of Fame Nomination Form

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Contact

Mail corresponding Attachments postmarked by February 15 to:

Gulf Coast State College
Attn: Daryl White
5230 W. US Highway 98
Panama City, FL 32401

Should you have any questions or concerns contact Daryl White, Associate Director of Criminal Justice and Law Enforcement Programs

850.769.1551 ext. 5612
dwhite6@gulfcoast.edu

Public Safety Hall of Fame Nomination Form

Attachment Checklist:

Summary of nominee’s professional public safety history. (Required)
Description of why nominee should be selected (include description of their contributions to public safety). (Required)
Agency/Department photo. (Required)
Proof of nominee’s outstanding performance, actions, accomplishments, and character (e.g. any professional acts of excellence above and beyond minimum standards). Examples include letters of recommendation, official reports, statements, newspaper article(s), and/or other media archive historical references.
Summary of civic contributions and/or humanitarian activities. Describe as completely as possible, the nominee’s local, state and national level of service in civic organizations. Include information about community involvement in public safety, charitable activities, etc. Also describe as completely as possible the nominee’s contributions in any humanitarian service. (Required)
List of awards and honors. (Required)

Application deadline is February 15 of the year of induction.

Please don't fill out this input box.

NOMINATION INFORMATION

Full Legal Name:

Home Address:

City:

State:

Zip Code:

Home/Cell #:

Work #:

Email Address:*

County of Residence:

How many years?:

Date of Birth:

Years in Public Safety:

Retired?

Yes

Month/Year retired:

Position(s) held:

Any honors/awards received? If yes, please include a list as attachment

Yes

Is nominee deceased?

Yes

If yes, year deceased:

Was nominee's death caused by an incident in the line of duty?

Yes

If yes, explain:

If Nominee is deceased, please provide family point of contact:

Full Name:

Relationship to deceased:

Home Address:

City:

State:

Zip Code:

Home/Cell #:

Work #:

Email Address:

NOMINATOR INFORMATION:

Full Name:

Title:

Agency/Organization:

Work Address:

City:

State:

Zip Code:

Work #:

Email Address:*

I hereby affirm the information contained herein is accurate to the best of my knowledge and understanding. The information provided is in congruence with the Nomination Guidelines. I agree to provide additional information if requested by the Gulf Coast State College Public Safety Hall of Fame Selection Committee.

Nominator's Name:*

Date:

NOTE: Only nominator will be contacted if the nominee is not selected. Nominee and nominator will be contacted if nominee is selected to be inducted.