Fill and Sign the Employment Separation Certificate Form

Page 1 of 2 Fish and Wildlife Service Fallen Comrades Memorial Nomination Form Purpose: Regional or Deputy Regional Directors and Assistant Directors use this form to nominate inductees into the Service’s Fallen Comrades Memorial wall (see 029 FW 5 for more information). Criteria for Inclusion in the Fallen Comrades Memorial: The Fallen Comrades Memorial includes the names of Service employees and regular agency volunteers who died in the line of duty. The employee's death must be the direct and sole result of injury or factors of employment that can be traced through a natural or unbroken sequence. We do not include in the Memorial employees who die due to preexisting medical conditions or while commuting to or from work. Inductees: Inductees may be any worker carrying out the mission of the Service and its predecessor agencies and regular Service volunteers. Selection Process: Regional and Deputy Regional Directors and Assistant Directors use this nomination form to nominate inductees. Send the form to the Service Historian at the National Conservation Training Center. A subcommittee of Heritage Committee will handle preliminary selection. The full Heritage Committee will make the final determination about inducting nominees into the Memorial. The Director or Deputy Director will approve the Committee’s determination. We wait at least 1 year after the subject’s death before adding his or her name to the Memorial. FWS Form 3-2304 03/10 Print Form Page 2 of 2 Nomination Form Fallen Comrades Memorial Name of fallen comrade (as it should appear on plaque): Last duty station: Date of death: Cause of death: Brief biography of fallen comrade: Nominated by (name and title): Nominating official’s Address: Phone number: Email address: FWS Form 3-2304 03/10