Certificate of Recognition & Resolution Request Form

We are happy to provide recognitions for constituents, businesses, nonprofits, and organizations that call Assembly District 76 home. All requests for certificates must be submitted using the form below.

Please submit this form at least 10 business days before needing the certificate. If you are requesting more than 10 certificates, please allow 15 business days for processing. Please include a mailing address for the certificates, in case our office is unable to attend the event/presentation.

*For requests including multiple certificates, you must submit a spreadsheet with all honoree names. Upon submitting this form, you will be prompted with a link to do so.
Allowed file types are xls, xlsx

For questions, please contact the district office at (858)-675-0760

First Name *

Last Name *

Address *

City *

Zip Code *

Phone Number

Ext.

Phone Number Type

Which type of certificate are you requesting? *

Certificate of Recognition (Standard)

Certificate of Appreciation

In Memoriam

Scholastic Achievement Award

Girl Scouts: Gold Award

Girl Scouts: Silver Award

Girl Scouts: Bronze Award

Scouting America: Eagle Scout Award

Requesting Organization *

Is this certificate request for a single individual or multiple honorees? *

Single Honoree

Multiple - I will submit the list using the link provided

Honoree First Name *

If multiple names, please list "Multiple" or input "N/A"

Honoree Last Name *

If multiple names, please list "Multiple" or input "N/A"

Honor/Award/Milestone Title *

ie: Teacher of the Year, Grand Opening, 50 years of service

Describe why this honoree is being awarded / Activity deserving of recognition *

If this is to celebrate a milestone, how many years has the event/accomplishment been occurring?

Would you like to request the Assemblymember or staff present this award? *

Scheduling Requests here: scheduling.assembly.ca.gov/a76

Event / Award Presentation Date *

Event / Award Presentation Start & End Time *

Event Address / Award Presentation Location *

Expected Number of Attendees *

What is the mailing address for the certificate(s) should the Assemblymember or office be unable to attend? *

Please be sure to include a unite or office number.

Any additional information you'd like to share?