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Certificate of Recognition Request

This form is designed to assist you in obtaining a certificate of recognition from Assemblymember Dr. Corey A. Jackson to acknowledge an individual's achievements, contributions, or participation in an event, program, or project.

To request a certificate of recognition, please complete the form below. We recommend giving us at least two weeks notice before you need the certificate to give us time to process your request.

Contact Information
Street Address
Honoree Information
Instructions: Please upload a document with the information of the honoree. Information should include name of honoree, title/position (if applicable), and reason for recognition.
One file only.
200 MB limit.
Allowed types: txt, rtf, doc, docx, odt, odp, xls, xlsx, ods.