MCPA Statewide Awards Nomination Form

MCPA Statewide Awards Nomination Form
Award Submission Requirements:
- All nominations must be submitted by a CLEO.
- If you are nominating someone from another agency, the nominee’s CLEO must be notified.
- A digital photo of the nominee must be attached in this form with the application.
- Nominations must be submitted by January 17, 2025 for consideration and presentation at the Executive Training Institute Awards Banquet in Rochester on Wednesday April 9, 2025.
Important: Please complete one nomination form per incident. If an incident involves more than five nominees, please submit an additional form.
Your Information (Nominator)

All nominations must be submitted by a CLEO.
Nominator Rank*
Nominator Name*

First NameLast Name
Nominator Agency*
Nominator Email*
example@example.com
1. Award Nominee Profile

Important: Please verify the accuracy of this information, as it will be printed on plaques and in the program.
Nominee Name*

First NameLast Name
Nominee Agency*
Nominee Rank*
Rank at the time of the incident for which the nomination is being made
Nominee Email
example@example.com
For which award are you nominating this person?*

Medal of HonorDistinguished Service AwardMeritorious Service AwardLifesaving AwardCitizen's Valor AwardPolice Cross
Would you like to nominate a second person for this same incident?*

YesNO
2. Award Nominee #2 Profile

Important: Please verify the accuracy of this information, as it will be printed on plaques and in the program.
Nominee #2 Name*

First NameLast Name
Nominee #2 Agency*
Nominee #2 Rank*
Rank at the time of the incident for which the nomination is being made
Nominee #2 Email
example@example.com
For which award are you nominating this person?*

Medal of HonorDistinguished Service AwardMeritorious Service AwardLifesaving AwardCitizen's Valor AwardPolice Cross
Would you like to nominate a third person for this same incident?*

YesNO
3. Award Nominee #3 Profile

Important: Please verify the accuracy of this information, as it will be printed on plaques and in the program.
Nominee #3 Name*

First NameLast Name
Nominee #3 Agency*
Nominee #3 Rank*
Rank at the time of the incident for which the nomination is being made
Nominee #3 Email*
example@example.com
For which award are you nominating this person?*

Medal of HonorDistinguished Service AwardMeritorious Service AwardLifesaving AwardCitizen's Valor AwardPolice Cross
Would you like to nominate a fourth person for this same incident?*

YesNO
4. Award Nominee #4 Profile

Important: Please verify the accuracy of this information, as it will be printed on plaques and in the program.
Nominee #4 Name*

First NameLast Name
Nominee #4 Agency*
Nominee #4 Rank*
Rank at the time of the incident for which the nomination is being made
Nominee #4 Email*
example@example.com
For which award are you nominating this person?*

Medal of HonorDistinguished Service AwardMeritorious Service AwardLifesaving AwardCitizen's Valor AwardPolice Cross
Would you like to nominate a fifth person for this same incident?*

YesNO
5. Award Nominee #5 Profile

Important: Please verify the accuracy of this information, as it will be printed on plaques and in the program.
Nominee #5 Name*

First NameLast Name
Nominee #5 Agency*
Nominee #5 Rank*
Rank at the time of the incident for which the nomination is being made
Nominee #5 Email*
example@example.com
For which award are you nominating this person?*

Medal of HonorDistinguished Service AwardMeritorious Service AwardLifesaving AwardCitizen's Valor AwardPolice Cross
If you would like to submit more than 5 nominees, please finish submitting this form and start a new form for any additional nominees.
Nomination Narrative

Except in special circumstances, nominations should be submitted for the 2024 calendar year.
Please upload a written statement of why this nominee(s) is deserving of the award. Be sure to include details on the situation, including time, date, location, and information that describes what happened and what actions the nominee took. Please also say why you feel the actions rise to the level of receiving this honor.

Cancelof
Please upload any additional documentation you would like the committee to review.

Cancelof
Photos

Please upload photos of your nominee(s).
Upload photo of Nominee #1*

Acceptable file types: jpeg, jpg, png
Cancelof
Upload photo of Nominee #2*

Acceptable file types: jpeg, jpg, png
Cancelof
Upload photo of Nominee #3*

Acceptable file types: jpeg, jpg, png
Cancelof
Upload photo of Nominee #4*

Acceptable file types: jpeg, jpg, png
Cancelof
Upload photo of Nominee #5*

Acceptable file types: jpeg, jpg, png
Cancelof
Please verify that you are human*
Should be Empty:

MCPA Statewide Awards Nomination Form

Your Information (Nominator)

1. Award Nominee Profile

2. Award Nominee #2 Profile

3. Award Nominee #3 Profile

4. Award Nominee #4 Profile

5. Award Nominee #5 Profile

Nomination Narrative

Photos