THE FRANCIS X. DONOVAN

FIRE PROTECTION INSPECTOR OF THE YEAR

2014

I. INSTRUCTIONS:

a. Attach additional pages as needed to give complete, detailed responses.

b. Nominations should be submitted by or with the approval of a County Association.

c. Submit nominations to NJFP&PA, PO Box 327, Springfield, NJ 07081-0357

ATTN: Executive Board.

d. Applications must be received by the Association Secretary by March 9, 2012.

e. You must submit three (3) copies of this application.

II. PERSONAL & EMPLOYMENT INFORMATION:

1. Name of Nominee: Title:

2. Name of Enforcing Agency the nominee is an appointed Fire Subcode Official or Fire Protection Inspector for:

3. Address:

4. City: Zip

5. Business Phone: Fax:

6. Number of Years with this Enforcing Agency:

7. Is this position Full Time r Part Time r

8. Nominee’s UCC License #:

9. Type of License:

10. List on attached pages any other Enforcing Agencies in which the nominee serves or served as a Fire Protection Inspector or as Fire Subcode Official. Include any other fire safety experience, job history and similar information including any that predates the UCC.

III. PROFESSIONAL AFFILIATIONS:

1. Member of the N.J.F.P.& P.A. ? Yes r No r Number of Years?

2. Offices Held:

3. Member of the County Fire Prevention & Protection Association. Number of years:

4. Offices Held:

5. List memberships on any national, state, or county boards, committees, councils or commissions which relates to the nominee’s duties & responsibilities as Fire Subcode Official or Fire Protection Inspector.

For each of the groups listed above, please indicate the level of participation such as offices held, committee chairmanships, or similar duties.

IV. COMMUNITY FIRE PROTECTION:

List and describe below any community projects or programs developed by the nominee which relate to fire protection or public fire safety. Attached additional pages, including supported documentation, letters of recognition, newspaper articles, and any other information.

V. REFERENCES:

Please supply three (3) references that the committee may contact with regard to this nominee. If the reference has particular knowledge about specific sections of this application please indicate that section number next to the person’s name.

Name: Phone:

Address:

Name: Phone:

Address:

Name: Phone:

Address:

1962 – OUR 52th YEAR OF DEDICATION TO FIRE SAFETY – 2014