New York Sate Campaign Safe and Sober

/ Annual New York State
MADD STOP-DWI Recognition Award forLaw Enforcement
Law Enforcement Agency Nomination

Download this form -

Agency Name:
Agency Street Address:
City, State Zip
Telephone: / Fax:
Chief/Sheriff Name Title:
Chief/Sheriff Signature

MADD Recognition Award -Police Agency Nomination (2/16)

During the calendar year, 2015:

Number of individuals arrested by your department for DWI (not number of UTTs):
Number of Zero Tolerance violations:
Number of underage drinking violations/detentions:
Number of establishments checked for sales to minors:
Does your department have personnel dedicated to a traffic enforcement unit, or in small departments, have an officer designated as the traffic enforcement officer?
Yes / No / Number assigned:
Number of officers trained in Standardized Field Sobriety Testing:
Number of officers certified to operate a breath test instrument:
Number of officers certified as Drug Recognition Experts
Agency size by number of full time and part time personnel
Full / Part
01-11
11-25
26-50
51-100
101-400
401 or more
How many crashes did your department handle during the period?
Property damage
Personal injury
Fatal
Alcohol related

MADD Recognition Award -Police Agency Nomination (2/16)

Describe activities or initiatives undertaken or supported by the department to enhance DWI enforcement efforts. For example: educational efforts, media coverage, specialized enforcement details, underage initiatives, etc. (During the calendar year, 2015.):

Attach any citations received by your agency for highway safety activities during the year (2015).

Please submit this application by April 4, 2016 by e- mail or fax. Applications received after that date may not be considered. If you have questions you may call Renée Borden at (518) 474-5111.

Submit by: Fax: (518) 473-6946or email please put DWI Nomination in the subject line.

Also: Please forward a copy of this completed application form to your County STOP-DWI Coordinator. To look up your county coordinator go to

MADD Recognition Award -Police Agency Nomination (2/16)