Cooper K. Craig-Mellmer Youth Leadership Award

Cooper K. Craig-Mellmer Youth Leadership Award

Nomination Form Presented by the Dickinson Police Department
Nominee Information
Name*

First NameLast Name
Age*
Email Address (if known)
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School/Organization (if applicable)
Parent/Guardian Information
First Parent/Guardian Name:*

First NameLast Name
Second Parent/Guardian Name:

First NameLast Name
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Can pictures be posted of this award recipient?*

YesNo
Nominator Information
Name*

First NameLast Name
Organization
Relationship to Nominee*
Name, Date, Time of Event Award will be Presented *
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Nomination Statement
Please include a 200–500 word written statement describing how the nominee demonstrates the core values of Integrity, Commitment, Professionalism, and Honor. Be specific — include examples, stories, and any relevant accomplishments that illustrate their leadership and impact. (You may attach the statement as a separate document if needed.)
Nomination Statement*
Additional Materials (Optional)
Letters of Support:

Cancelof
Photos, Project Summaries, or Documentation of community involvment

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Submission Questions can be directed to:

Dickinson Police Department

jarett.blain@dickinsongov.com

701-260-9948
Should be Empty:

Nominee Information