Operations & Engineering Section
400 N. Capitol Street, NW Suite 450
Washington, DC 20001
2016
APPLICATION FOR MERITORIOUS SERVICE AWARD
AND/OR CERTIFICATE
1. Name of employee for whom application is made______
2. Residence address of employee______
______
3. Age______
4. Occupation______
5. Employing Company and Address______
______
______
6. Place service was rendered______
7. Date service was rendered______
8. Time service was rendered______
9. Character of service rendered --- Give full and accurate details with drawings and photographs of location if necessary to render full description.
10. Attach the following material to this application:
A. Statement by a doctor who attended.
B. Any available reports, statements or evidence in support of this application.
Signature of company executive:
Name______
Title______
Date______
Return by February 1, 2016 to: Ms. Debbie Ellis
Operations & Engineering Services Specialist
American Gas Association
400 N. Capitol Street, NW, Ste. 450
Washington, DC 20001
E-mail:
Fax: 202-824-9188
(Application regulations on next page)
REGULATIONS UNDER WHICH
A MERITORIOUS SERVICE AWARD IS MADE
1. This Award is designed to recognize gas industry employees who have shown meritorious and conspicuous judgment, intelligence or bravery in saving a human life.
2. Not more than one Award will be made annually for a period covered by the prior calendar year – provided a sufficiently meritorious act was performed that year. However, a number of certificates may be awarded each year.
3. This Award will be presented by and with the authority of the Operating Section Executive Committee of the American Gas Association.
4. To be eligible for the Award, the recipient must be an employee of a gas utility or transmission company that is a member of the American Gas Association
5. The Operating Section Executive Committee may present a posthumous award in memory of one who is survived by a spouse, parent or child who can accept the award on her/his behalf.
6. The application for the Award must be signed by an executive officer of the employing company and should be submitted to the staff executive of the Safety & Occupational Health Committee at the American Gas Association.
7. Applications covering a period from January 1 to December 31 are to be filed with the staff executive of the Safety & Occupational Health Committee of the American Gas Association, by a date to be specified by AGA each year.
8. In years that an Award is made, it will be presented at the annual Operations Conference of the American Gas Association.
9. The Operating Section Executive Committee of the American Gas Association may at any time make any regulation or requirement governing this Award not inconsistent with the foregoing requirements.
APPROVED BY AGA SAFETY & OCCUPATIONAL
HEALTH COMMITTEE
______
Chairman, Safety & Occupational Health Committee Date
______
Committee Member Date
______
Committee Member Date
______
Staff Executive, American Gas Association