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Safety Star Recognition Program

2. Safety Star Recognition Form
   Fill-in the necessary information to recognize a fellow employee for exception safety standards exhibited while on the job, here at the City of Anacortes
4. First Name of Nominee*
5. Last Name of Nominee*
7. Department
   Enter the Department the employee works under
8. Approximate Date*
   Approximate Date
   Insert date that you witnessed this behavior
10. Reason for Nomination*
    Write-up a detailed explanation of what you witnessed this employee doing that expressed Safety Standards that warrant this nomination
12. This form has been submitted by:*
    Full name of employee submitting the nomination
13. Last Name*
Leave This Blank:


15. 1. Receive an email copy of this form.
16. Email address

    This field is not part of the form submission.

17. Submit

* indicates a required field