NATA Lifesaver Recognition |

Lifesaver Name: *

Address: *

Phone: *

E-mail: *

Lifesaver’s NATA Member ID Number:

Date of Lifesaving Event: *

Location of Lifesaving Event: *

Description of Lifesaving Event: *

Submitted by: *

Submitter Address: *

Submitter Phone: *

Submitter E-mail: *

Please attach any two of the following verification items:

A copy of a newspaper article covering the event
A copy of a radio/television report covering the event
Letter from individual(s) rescued
Letter from an immediate family member of individual rescued
Letter from a bystander or witness to the event*
Letter from attending medical personnel (EMT, Paramedic, Emergency Room Physician)*
Letter from lifesaver’s supervisor/employer verifying the event

*Letters from 2 separate individuals are acceptable.

Verification Item 1: *

Verification Item 2: *