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.

You can confirm which district you are located in here: District Locator.
If you are not a resident of LA County, please request a scroll from the Chair: Hilda Solis office.

Requests are required a minimum of four weeks before the date needed. Please fill out all information applicable; missing or incorrect information can delay processing the requested certificate(s).

For multiple recipients, please fill out this form.

Do not alter format or use all CAPS, please fill out names with the proper capitalization they should be printed on the certificates.
If requesting certificates for 5 or more recipients, please include all recipients’ first and last names (capitalize ONLY the first initial for both) together under the Recipient Column. No need to modify the other columns.

A certificate request does not guarantee a certificate.

Today's Date*
MM slash DD slash YYYY
Requester Info
Requester's Name*
First Last
Preferred Pronouns
Requester's Telephone Number (no spaces, dashes or parentheses)*
Requester's Email*
Recipient Info
Recipient Name*
Recipient Role (e.g. participant, host, graduate, awardee of [x] award, honoree of [x] honor)*
Recipient Address*
Street Address Address Line 2 City State ZIP Code
Organization Name*
Organization Address*
Street Address Address Line 2 City State ZIP Code
Do they reside in the Third District?*
If requesting County Employee Retirement commendation, please submit your suggested "whereas" language (200 words max): in chronological order with starting stitle and Department, any subsequent roles and departments, and job responsibilities/career accomplishments.
If requesting retirement commendation, please include: Starting and ending job title, Start Date, Retirement Date, Division, Department name
Doctorate Type (if applicable): MD, JD, PhD, MD, EdD, DNP, MPH, DBA, DMA, etc.
Law Enforcement/Military/Clergy rank (if applicable):
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.

Certificate Request

Requester Info

Recipient Info

HONOREE INFORMATION

DELIVERY