December 10, 2017
Dear Association Member;
You may return the filled out forms via US mail or you can send them to me via email at .
The banquet will be held on March 10th, 2018 beginning at 6:30 PM and hosted by the West Yadkin VFD.
Enclosed you will find a nomination form for officer of the year. Please nominate one member from your department for this event.
The form, MUST BE RETURNED NO LATER THAN
February 1st, 2018
Return to:Yadkin County Volunteer Fire and Rescue Association
Dale Potts
3300 Chinquapin Road
Yadkinville, NC 20555
463-2299 Home
971-2299 Mobile
Sincerely,
Dale Potts
Dale Potts
Secretary
OFFICER OF THE YEAR
Each department should submit a nomination letter for their nominee containing at a minimum the information attached. You should provide the committee with as much information as possible to assist them in their selection. Information for nominee should be for the past year to date.
Nominations must be submitted to the Nominating Committee no later than February 1st, 2018. The awards will be presented at the 23rd Annual Awards Banquet to be held March 10th, 2018 at 6:30 PMand hosted by West Yadkin VFD.
Department Name:______
Nominee Name:______
Marital Status:______
Number of Children and Ages:______
Nominee’s Age and Birth Date:______
Chief’s Name: ______
CERTICATIONSDATE COMPLETED
Firefighter I______
Firefighter II______
ERT / RT / TR______
NCDOI Instructor______
Hazmat Awareness______
Hazmat Operational______
Instructor______
CPR______
Instructor______
Yadkin County First Responder______
NC Medical Responder______
NC EMT - Basic______
NC EMT - Intermediate______
NC EMT - Paramedic______
Firefighter I and II / Rescue Technician / Technical Rescuer individual classes
(LIST or Print NC OSFM Transcript:
______
______
Calls#Fires #House/Medical#Rescue#10-50
Department Dispatched______
Nominee Response ______
Nominee Status
Date Nominee entered Department______
Years of Service if applied
_____Fire_____Traffic_____Medical_____Rescue_____Board of Directors
_____Auxiliary _____Other
OFFICER(s)
Date AppointedRank or TitleDept
______
______
______
______
______
______
______
______
______
______
Quantity of Participation
HOURS OF TRAINING
Training at your Department______
North Carolina State Sponsored Schools______
Another County______
Another Department______
National Academy______
Other (Specify)
______
______
______
______
______
OTHER HOURS
Officer Training______
Business Meetings______
YCVFRA Meetings______
First Responder Meetings______
Chiefs Meetings______
State Association Meetings______
Other County Association Meetings______
EMS and Rescue Programs______
Public Education______
Teaching at your Department______
Teaching at other Departments______
Truck Maintenance______
Facility Maintenance______
Truck Cleaning______
Equipment Cleaning______
Facility Cleaning______
Administration______
UNITS CERTIFIED TO OPERATE
Pumper_____Other
Tanker_____
Brush _____
Equipment_____
Quick Response_____
Ambulance_____
Rescue_____
Boats_____Last EVD Course:
********GIVE NOMINATION FORM TO CHIEF FOR REMARKS********
OUTSTANDING ACTION(s) ON A CALL
OUTSTANDING CONTRIBUTION(s) TO THE DEPARTMENT
LIST PAST AWARDS, ACHIEVEMENTS
REASON FOR NOMINATION
********GIVE NOMINATION FORM TO CHIEF FOR REMARKS********
QUALITY OF PARTICIPATION OR PERFORMANCE
ATTENDANCE:EXCELLENTGOODFAIRPOOR
BUSINESS MEETINGS______
DRILLS______
FIRES______
RESCUE______
ASSOCIATION MEETINGS______
CHIEFS MEETINGS______
COOPERATION:
AT DRILLS AND TRAINING PROGRAMS______
SERVES ON COMMITTEES WHEN ASKED______
OTHER SPECIAL ACTIVITIES______
WILLINGNESS TO WORK:
ASSIST IN TRAINING PROGRAMS______
ASSIST IN TRAINING PROJECTS______
ASSIST IN SPECIAL ACTIVITIES______
DEPENDABILITY______
TRAINING:
ATTENDS AND PARTICIPATES______
ATTENDS SPECIAL TRAINING SCHOOLS______
ATTENDS OUT OF TOWN TRAINING______
EQUIPMENT:
ABILITY TO USE ALL EQUIPMENT______
INTEREST TO COMMAND AT INCIDENTS______
TRAINING ABILITY ON THE EQUIPMENT______
LEADERSHIP______
FIREFIGHTER/RESCUE:
QUALIFICATIONS______
ABILITY TO COMMAND______
ABILITY TO SIZE UP AND ACT______
ABILITY TO GIVE ORDERS______
COUNTY ASSOCIATION:
ATTENDANCE______
PARTICIPATES IN COUNTY ACTIVITIES______
SERVES ON COMMITTEES WHEN ASKED______
OUTSTANDING PERFORMANCE (IF APPLICABLE):
DEPARTMENT LEADERSHIP______
HEROIC DEEDS______
LIFE SAVING PERFORMANCE______
OTHER COMMUNITY SERVICES______
CHIEFS COMMENTS
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