Nomination Form

CITY OF BEVERLY HILLS

HEALTH AND SAFETY COMMISSION

BEVERLY HILLS COMMUNITY HEALTH AND SAFETY RECOGNITION PROGRAM
NOMINATION FORM

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Nominee's Name:
Nominee's Address:
Nominee's Phone Number:
Nominee's E-Mail:
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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.

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Nomination submitted by (print your name):
Your Address:
Your Phone Number:
Your E-Mail:
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