Medal of Honor Form

Medal of Honor Nomination Form

If you any questions or issues please contact:

Rebekah Taylor
Office: 225.342.1684
Cell: 225-721-3592
rebekah.taylor@lcle.la.gov

Step 1 of 2

Name of Officer: *

First

Middle

Last

(Please be sure to double check spelling of name – this will be the name to appear on the Medal.)

Date of Birth: *

Date of Birth:

End of Watch Date: *

Rank/Title: *

Years of Law Enforcement Service: *

Employing Agency: *

Agency Contact: *

(This should be the person at the agency who can answer questions about the nominated officer, any agency personnel to be involved in the ceremony, and any family members attending the ceremony.)

Contact’s Phone: *

Contact’s Email Address: *

Provide the estimated number of family members who will attend the ceremony *

If available; please list the names of the family members who will attend the ceremony, and each one’s relationship to the nominated officer: (This number needs to be as accurate as possible in order to plan for necessary seating.)

Provide a brief description of circumstances that lead to the death of the nominated officer: *

Provide two quotes from close professional associates of the nominated officer. Include the name and rank of each person quoted. (The quotes can include insight into the nominated officer’s character, professionalism, civic mindedness, sense of duty, etc. – the quotes may also include a personal experience or story about the nominated officer. The quotes should be limited to 2-3 sentences, and will be printed in the ceremony program.):

Identify two officers, from your agency, who will serve as Family Escort Officers at the ceremony – Include name, rank and email address for each escort officer: (These officers will be responsible for the following – escorting the family members into the ceremony, sitting with the family members during the ceremony, assisting the family members with collecting items presented, and attending to any other needs of the family members before/during/after the ceremony.)

Officer #1 Name *

First

Middle

Last

Officer #1 Rank *

Officer #1 Email *

Officer #2 Name *

First

Middle

Last

Officer #2 Rank *

Officer #2 Email *

Each agency is requested to provide an agency patch and photo of their fallen officer – electronic files are the preferred method of submission for both the patch and the photo – (Upload on website using the method below or emailed to rebekah.taylor@lcle.la.gov). If electronic files are not available, the patch and photo (8×10) should be mailed (LA Commission on Law Enforcement, P.O. Box 3133, Baton Rouge, LA, 70821 ATTN: Medal of Honor).

Each agency is responsible for contacting the family members of your fallen officer – the “agency contact” designated on this form will receive all necessary information for the family members from LCLE Staff. This information will include the ceremony date, location, and time, and a schedule of the ceremony day. It will be the responsibility of the “agency contact” to inform the family members of the information necessary for them to attend the ceremony and any related events.

PLEASE NOTE: It is VERY IMPORTANT to submit the completed nomination form, photo of the nominee, and agency patch as soon as possible…all necessary elements of the ceremony are dependent on this information being received in a timely manner. ALL information requested on the nomination form is necessary for the ceremony, so please make EVERY EFFORT to submit a COMPLETED nomination form as soon as possible!

Picture and Patch

Click or drag files to this area to upload. You can upload up to 3 files.

Medal of Honor Nomination Form

If you any questions or issues please contact:

Rebekah TaylorOffice: 225.342.1684Cell: 225-721-3592rebekah.taylor@lcle.la.gov

Rebekah Taylor
Office: 225.342.1684
Cell: 225-721-3592
rebekah.taylor@lcle.la.gov