Inland Empire Heroes Nomination
Award Categories (Select One)
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Please Select
Animal Welfare Hero
Corporate Hero
Disaster Services Hero
First Responder Hero
Gift of Life Hero
Good Samaritan Hero
Service to the Armed Forces Hero
Youth Hero (age 18 or younger)
Hero Nominee Information
Nominee Name
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First Name
Last Name
Nominee Occupation
Nominee Street Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Nominee Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Nominee Email
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example@example.com
Nominee County of Residence
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Please Select
Riverside County
Coachella Valley/Morongo Basin
San Bernardino County
Hero Nominator Information (You)
Nominator Name
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First Name
Last Name
Nominator Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Nominator Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Nominator Email
*
example@example.com
Nominator’s Relationship to Nominee
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Does your nominee know they are being nominated?
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Yes
No
Nomination Statement
Please describe what makes you or your nominee a hero.
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Media Coverage
Was this story covered by local media? If so, please share any links to online media coverage.
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Additional Information
If able, please include names and contact info for witnesses or friends/family of the nominee whom we can contact for additional information and/or verification as needed.
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How did you hear about this award opportunity?
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