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About the person you're nominating:

Name of individual or group (required)

If you are nominating a group please list all names, ages and dates of birth on a separate sheet

Address (required)

Daytime Tel No (required)

Date Of Birth (required) (ie. 15/07/90)

Nominee Email (required)

About You (You must be over 18):

Name of individual or group (required)

Address (required)

Daytime Tel No (required)

Your Email (required)

Your relationship with nominee e.g Group leader, parent etc

Please tick each box to confirm:

 I am over 18 years of age
 My nominee has been involved in helping the local community and has not received any form of reward or payment
 Approval has been given by the parent/guardian

Further references can be obtained from:

Ref 1 Name

Daytime tel No

Email address

Ref 2 Name

Daytime tel No

Email address

Please give a brief description of how your nominee(s) has helped the community, a person, an organisation, community group or their school. (maximum 200 words)

What impact has their actions have had? (maximum 200 words)

What difference they have made to a particular person, group or the community as a whole. (maximum 200 words)

You can send any further information or photographs you feel we might like to see to the following address.
Al Yusuf, LANPAC Office, Lancashire Constabulary HQ, PO Box 77, Hutton, Preston PR4 5SB
If you are unable to submit this form then please email the details to al.yusuf@lancashire.pnn.police.uk

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