Certificate Request

Certificates are intended to recognize and honor individuals or organizations for their contributions to Los Angeles County.

Certificates are issued to current Third District residents or organizations.

Requests are required a minimum of four weeks before the date needed.

A certificate request does not guarantee a certificate.

Today's Date*
MM slash DD slash YYYY
Requester's Name*
First Last
Requester's Telephone Number (no spaces, dashes or parentheses)*
Requester's Email*
Honoree Name/Organization Name*
Honoree/Organization Address*
Street Address Address Line 2 City State ZIP Code
Do they reside in the Third District?*
If requesting retirement commendation, please submit your suggested "whereas" language. Keep to a maximum 800 character limit.
If requesting retirement commendation, please submit job title, years of service, division, department name, and retirement date.
HONOREE INFORMATION
Title of Award (if applicable)
Event Name*
Event Date (must submit this form at least four weeks before this date)*
MM slash DD slash YYYY
Event Address*
Street Address Address Line 2 City State ZIP Code
Date to be Printed on Scroll/Commendation*
MM slash DD slash YYYY
Are you requesting presentation by staff to present scroll/attend event?*
Indicate whether you'll be picking up the scroll/commendation or if you'd like our office to mail it out (provide mailing address in the next field, if so)*
Mailing Address
Street Address Address Line 2 City State ZIP Code
Reason for Honor (if Memoriam, please indicate date of birth and date of passing)*
Indicate supporting documents (if applicable)
Max. file size: 5 MB.
Please upload organization logo (if applicable)
Max. file size: 5 MB.
I certify that the information contained in this request is accurate and complete, and that I've checked for spelling and grammar.*
I understand that due to the high volume of requests, Supervisor Horvath's office may not be able to accommodate the request, even if all outlined criteria are met.*
DELIVERY
Please note: Certificates and commendation requests must be submitted four weeks prior to the date needed. Requests will be reviewed and the requester will be notified of approval or denial in a timely manner. Due to the high volume of requests, the Supervisor's office may not be able to accommodate your request even if the criteria outlined above are met.
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Certificate Request

HONOREE INFORMATION

DELIVERY