Firefighter of the Year Nomination Form

2007 Firefighter of The Year Nominee

(Sponsored by Vernon Yelk Insurance Agency, Marshall, Bauer Built Inc. of Durand and W.S. Darley Co.)

Deadline: January 4, 2008

Committee Members: Dallas Millard, Jim Stormer, Steve Krause, and Peter Busch

Name of Nominee:____________________________________________________________________________

Address:____________________________________________________________________________________

City:_______________________________________________________________________________________

Nominee is a member of: ______________________________Fire Department____________________________

Fire Chief’s Name ____________________________________________Telephone No:_____________________

Address: ___________________________________City:_______________________________Zip____________

Name of Department or Association submitting nomination:____________________________________________

Chief of Dept. or President of Assoc. ________________________________Telephone:______________________

Address: ___________________________________City: ________________________________Zip___________

Information About Nominee:

Please answer all questions and provide other information you have on the nominee

Nominee’s Age:_______________________________

Married: _________________________Single_______

Number of Children:____________________________

Years of Service:_______________________________

*Volunteer _________Paid on Call ________Paid:_____

*If volunteer, nominee’s occupation:_______________

_____________________________________________

Leadership/Elected Positions held on Department:

Total Years:___________________________________

Position:______________________________________

Number of Years:______________________________

Position:______________________________________

Number of Years:______________________________

Position:______________________________________

Number of Years:______________________________

Member of Rescue Squad/Ambulance 1 Yes 1 No

Total Years – First Responder/ EMT:______________

List all training/special courses completed and certified:

_____________________________________________

Complete Attendance Record/Percentage:

Fire Calls___________% Rescue Calls__________%

Training____________% Regular Meetings______%

Describe Ability to Work with Other members of Dept: (Must include a letter from the Chief of Dept. If Chief is nominee, letter from an officer)

__________________________________________

Character References Other than Department Members (attach separate letters)

Fire Safety Programs:_______________________

Community Service Other Than Fire Department
Activities:___________________________________

___________________________________________

Acts of Heroism: (Please describe)_______________

____________________________________________

Any special activities/service not listed above:

(Armed services, VFW, DAV, Peace Corps, etc.)

____________________________________________

Please attach a letter with additional pertinent information. The winner and spouse will have all expenses paid at the convention and receive a plaque in their honor. A certificate only will be presented to all qualifying entries submitted.
Send to: WI State Firefighters Association, P.O. Box 126, Durand, Wisconsin 54736-0126. Deadline: January 4, 2008.

Sponsored by Vernon Yelk Insurance Agency, Marshall, Bauer Built Inc. of Durand and W.S. Darley Co.

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