In Honor Of Service Award

Deadline for submission February 15, 2019


I would like to apply for:










 
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:


APPLICANT’S INFORMATION:

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

Applicant's E-Signature: Date:



Name:
Phone:
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: