Request A Certificate

All requests for certificates must be submitted using the form below. Please submit this form at least 14 business days before you require the certificate.

For any questions, please contact the district office at (213) 483-5252 or email rob.chua@asm.ca.gov.

Indicates required field

Contact Information

First Name

Last Name

Title

Requesting Organization

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Work Phone

Cell Phone

Honoree Information

First Name

Last Name

Honor/Award Title

Type of recognition/description of honor (Ex. “Teacher of the Year” or “Chamber of Commerce Ribbon Cutting”)

Accomplishment

Describe the accomplishment of this honoree.

Multiple Honorees

If you are requesting more than one certificate, please upload a Microsoft Excel spreadsheet (xlsx). Please enter the first and last names of the awardees, their honor/award title, and a short description of their accomplishment.

One file only.
200 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Event Information: Request the Assemblymember to present the certificate

Date/Time

Location

Expected number of attendees

Additional Information

Note: If the Assemblymember or staff is unable to attend your event, pick up instructions for the certificates will be provided.

Contact

Capitol Office

District Office