Highway Angel Nomination Form

    (If using an Internet Explorer browser, please use the following format for the date field: "mm/dd/yyyy")

    Driver Details

    Photos must be 300 dpi (print-compatible) and labeled with the nominee's name. Please ensure only the driver's head and shoulders are visible with a solid background.

    Company Details

    Incident Details

    Example: 02:00

    Please fax additional documentation, if available, to (703) 836-6610, such as a copy of the police report, a clipping from a local newspaper, a statement from the employer on company letterhead, etc. TCA uses such documentation to verify that the incident took place as described to us. Please ensure the fax includes "Attention Highway Angels Program" on the cover sheet and that the driver's name is clearly visible so we can match it up with this form when you submit it.

    Nominator Details:

    Check One:
    If other, please specify