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Alberta Emergency Services Medal (AESM)/Service Bars Nomination Form
The personal information on this form is being collected to administer nominations for the Alberta Emergency Services Medal and its collection is authorized under section 33(c) of the Freedom of Information and Protection of Privacy (FOIP) Act. All personal information collected will be managed in accordance with the privacy provisions of the FOIP Act. If you have any questions regarding the collection of this personal information, please contact the Office of the Fire Commissioner at 1-866-421-6929 Fax: 780-415-8663, Calgary Police Service at 403-428-6100 and Alberta EMS Awards Committee at 780-638-2458 accordingly.
I certify that the person named in part "A" has served the organization(s) listed for the period(s) of time stated and in every way is deserving of the Alberta Emergency Services Medal/Service Bars.
X Date (yyyy-mm-dd) Nominator’s Signature
Please attach a letter of confirmation from each Department listed under in Section "A".
Surname First Name/Initials Municipality Address
Position Telephone Number Recommendation (Yes or No)
X
Please forward the completed nomination form to:
Structural Fire:[email protected]
Emergency Medical Services: [email protected]
Wildland/Wildfire: [email protected]
Law Enforcement: [email protected]
Environmental Responders: [email protected]
Other nominations: [email protected]
Mailing Address: Office of the Fire Commissioner, Public Safety Division, Alberta Municipal Affairs 16th Floor, Commerce Place 10155-102 Street Edmonton, Alberta T5J 4L4 Email: [email protected] Search and Rescue:
Page 1 of 1OFC0001 (2017/10)
Surname Given Names Gender Birth date: Rank
Home Address City Postal Code Your MLA Representative (if known)
Discipline (please check all that apply to candidate's history)
Police Dispatch Fire EMS
Search and Rescue Other (describe): ______________________________________
Service From Month - Year
Service To Month - Year
Department Position
AESM Service bar 22‐year Service bar 32‐years Service bar 40‐years
Surname First Name/Initials Position
Municipality Mailing Address Telephone Number E-mail:
A. Recipient
B. Award
C. Nominator Endorsement
D. Awards Committee/Authority Approval (For Internal Use)
Date (yyyy-mm-dd)
Government of Alberta
If there is more information than will fit in the above boxes, please attach a separate sheet.
NOTE: Information that is not legible could result in a delay in processing your application