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In Honor Of Service Award

Deadline for submission Monday, February 6, 2017

All fields are required below.

I would like to apply for:
Cecil K. Leberknight Award (10 Years or more of Service)
Thomas F. Chrostwaite Award (20 Years or more of Service)
Carol Sambol Award (25 Years or more of Service)
Board of Directors’ Award (30 Years or more of Service)
Donald E. Carman Award (35 Years or more of Service)
President’s Award (40 Years or more of Service)
Trustees’ Award (45 Years or more of Service)
Charles F. LeeDecker Award (50 Years or more of Service)
Past Presidents’ Award (55 Years or more of Service)
Paul Santangelo Award (60 Years or more of Service)
 

Yes No    Is this nomination intended to be a surprise for the recipient?

 
APPLICANT'S STATEMENT OF SERVICE:

I, , have been in the service of the Borough of , since the day of , in the year of , as defined by the PSAB Bylaws for service awards. I have served the borough as a mayor, council member, manager, secretary, or treasurer.
 
 
POSITION:(Only positions listed above are eligible)

From: To:

From: To:

From: To:

Total Number of Years:

I do solemnly swear that the foregoing statements are true to the best of my knowledge.

Applicant's E-Signature: Date:
 
 
APPLICANT’S MAILING ADDRESS:

Street:
Borough:
Zip:
Email:
 
 
BOROUGH SECRETARY/MANAGER CERTIFICATION OF APPLICANT’S SERVICE:
If application is for the secretary/manager, president of council should certify.

I certify that I am the Borough Secretary or Manager of the above mentioned borough and that the information listed above is true to the best of my knowledge.

Secretary/Manager Name:
Phone:
Secretary/Manager E-Signature:
Date:
 
 
SECRETARY/MANAGER MAILING ADDRESS:

Street:
Borough:
Zip: