Senator Bob Regola, 39th Senatorial District

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Good Citizenship Award Submission Form

I would like the awards mailed to our school

I would like to have the award presented at our ceremony if possible.

Name of School:

School Principal:

Nominating Teacher (For contact purposes):

School address:

Office Telephone: Fax:

Date and Time of Awards Ceremony:

Location & Room of Ceremony:

Names of Award Recipients:

Female Student:

Grade Level 2007 - 2008

Brief Description why nominated:

Male Student:

Grade Level 2007 - 2008

Brief Description why nominated:

Please complete this form and click the submit button. The form will be mailed to Jeannie Rings.

You also may fax the form to my North Huntingdon Office at(724) 861-7019 before April 15, 2008.