Highway Angel Nomination Form

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

Driver Details

Driver's Name*

E-mail Address*

Address Line 1*

Address Line 2

City*

State/Province*

Zip/Postal Code*

Country*

Phone*

Tractor Number*

Driver Headshot*

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

Trucking Company*

Phone*

Address Line 1*

Address Line 2

City*

State/Province*

Zip/Postal Code*

Country*

Incident Details

Date of Angel Incident*

Time of Angel Incident*

Example: 02:00

City of Angel Incident*

State/Province of Angel Incident*

Describe Angel Incident

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:

Same as Company Details

Your Name*

Your Company*

Your Title*

Address Line 1*

Address Line 2

City*

State/Province*

Zip/Postal Code*

Phone*

Email*

I am*
Check One:A representative from the driver's company.A motorist or victim who was helped by this driver.Affiliated with the police department, fire department, emergency services, etc.The driver's friend or family member.The driver, nominating myself.Other

If other, please specify

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