Application Form

NBAFC Awards Selection Committee
896 Chartersville Road
Dieppe, NB E1A 1L1
NEW BRUNSWICK ASSOCIATION OF FIRE CHIEFS (NBAFC)
CERTIFICATE OF COURAGE
APPLICATION
Nominee's Name:
DOB:
Address:
City:
Male
Female
Fire Department:
Job Duties:
The NBAFC Certificate of Courage is awarded to any firefighter (s) who has clearly distinguished themselves by displaying great courage
while under minimal risk of personal injury. This includes attempting to save or saving a life or preventing substantial loss of property.
Firefighters who receive this honor have usually performed acts that clearly show courage or bravery.
For the purpose of this award, a firefighter is defined as a person serving a public agency, with or without compensation, as a firefighter.
This nomination is made in the following category:
The nominee saved or attempted to save a life.
The nominee prevented a substantial loss of property.
The nominee displayed exceptionally meritorious conduct while in the performance of duty
(to be determined)
(to be determined)
Please provide a brief summary of the incident:
Provide at least two names, addresses and telephone numbers of individuals who witnessed this act:
Name
Address:
Telephone:
Name
Address:
Telephone:
Please remember, it is important that you attach a detailed description of the incident, any supporting documentation
(newspaper articles, photographs, witness statements etc.) to assist the selection committee when considering this application.
Name of submitter:
Phone:
Address:
E-mail address:
Print Form
Date