Fillable The Secretary of the State of Connecticut (State of Connecticut/Department of Administrative Services)

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The Secretary of the State of Connecticut (State of Connecticut/Department of Administrative Services)

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The Secretary of the State of Connecticut
Requests may be e-mailed to lourdes.montalvo@ct.gov or faxed to 860.509.6209
Please fill in the required information below:
Office of the Secretary of the State of Connecticut
Secretary of the State Denise W. Merrill
Would like to recognize
Why is this individual being recognized:
(ex. Your hard work and dedication within
your community)
Name as it should appear on the certificate:
If there are multiple recipients for the same
award please separate each name with a
comma. (ex. Sarah Smith, Emma Ross)
Name of award:
(ex. 2016 Lifetime Achievement Award)
Date to appear on the bottom of the
certificate:
.
Please complete the information below regarding the contact person. Certificates will be mailed to this person.
Name:
Title (if applicable):
Address:
(including zip code)
Phone number:
Email address:
If you have any questions or require additional information please contact Lourdes Montalvo at lourdes.montalvo@ct.gov or
860.509.6202.
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The Secretary of the State of Connecticut (State of ConnecticutDepartment of Administrative Services)

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Completed 13 August 2020

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