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Health and Safety Commission Recognition Award Online Nomination Form
CITY OF BEVERLY HILLS
HEALTH and SAFETY COMMISSION
BEVERLY HILLS COMMUNITY HEALTH AND SAFETY RECOGNITION PROGRAM

NOMINATION FORM

Nominee's Name:

Nominee's Address:

Nominee's Phone Number: E-Mail:

Please briefly describe the achievements of the nominee and explain why you feel this individual, business or group's efforts have significantly improved community health, safety and/or emergency preparedness in Beverly Hills. Provide specific examples using the criteria on the reverse side of this form. Attach additional sheets if needed. All information provided is subject to verification.


Nomination submitted by (print your name):

Your Address:

Your Phone Number: E-Mail: