Apply for Membership

Please complete the following information to submit your Honor Roll application electronically. The Organization Leader you indicate under the Organization Information section of this form will be contacted to schedule your organization's proclamation at the state capitol. Membership in the Honor Roll is only available to Nebraska organizations.

Required fields are displayed in bold.

Organizational Information

Organization/Community: Contact Person: Email: Phone: Fax: Address: City: State: Zip: Organization Leader:

Safety Belt Usage

Enter the results of two unannounced observational surveys conducted in parking lots at least 30 days apart. Usage rates from each survey must be 90% or greater to qualify for the Honor Roll. These are due by the end of the month for presentation by the Governor in the following month:

Survey #1

Date: Total # Observed: # Wearing Safety Belts: % Wearing Safety Belts: Name(s) of Observers:

Survey #2

Date: Total # Observed: # Wearing Safety Belts: % Wearing Safety Belts: Name(s) of Observers:

Please provide a brief summary of the data collection procedures used: