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Special Olympics Wisconsin Dale Brunner Law Enforcement Hall of Fame Award - Nomination Form

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Name of Special Olympics Wisconsin Dale Brunner Law Enforcement Hall of Fame Award Nominee:

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Rank / Title of Nominee:

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Law Enforcement Agency/Organization:

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Please enter phone number of nominee

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Email Address of nominee:

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Business Address with City, State & Zip:

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Contact Information of Nominee's Supervisor including Name, Phone & Email:

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How many years has the nominee been involved with the Torch Run?

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Please explain any State or National involvement with LETR and/or SOWI :

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Please list the nominee’s involvement with Special Olympics and the Torch Run. Please be specific and highlight activities, positions held (coaching athletes, etc), accomplishments, length of service, money raised, sponsors acquired, etc. – Local involvement (town, city):

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What impact has this person had on furthering the mission of the Wisconsin Torch Run?

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Please explain any International involvement or international conference attendance:

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Please list any other information you believe the selection committee should know about the nominee:

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Person completing this form:

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Please enter your phone number

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Your Best Email Address *

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Special Olympics Region if known:

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Your Involvement with Torch Run:

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