Minneapolis Health Department

Public Service Center
250 S. 4th. Street, Room 510
Minneapolis, MN 55415
health@minneapolismn.gov
612- 673-2301

Submit permits in-person
at the customer service
counter on 3rd floor of
Public Service Center.

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Public Service Center

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Purpose

Process

Nomination Form

**Please keep in mind an individual or division can only receive the award once a year. If someone received the award as part of a division, they can be nominated again as an individual for a different reason.

Today’s Date:

   

Nominator’s Name (optional):

 

Name(s) of Nominee(s):

 

Nominee’s Division:

 

Reason for Nomination
Please be as specific as possible. The Recognition Team may not be familiar with the work of the individual/division. Please keep the nomination guidelines in mind as you complete this form.

How has the nominee contributed to the MDHFS or City goals?

View MDHFS Goals View City Goals


Please email this form to either
Bill Smoger or Diane Haugesag. You can also submit this form via the Skipper Award Nomination folder in the PSC 510 Break Room.

Last updated Sep 10, 2012

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Accessibility:
For reasonable accommodations or alternative formats, contact 311.
People who are deaf or hard of hearing can use a relay service to call 311 at 612-673-3000.
TTY users can call 612-673-2157 or 612-673-2626.

Para asistencia 612-673-2700, Yog xav tau kev pab, hu 612-637-2800, Hadii aad Caawimaad u baahantahay 612-673-3500. 

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