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EMS Service Information

Note: Nominations must be made by someone other than the organization's Owner and/or Director (e.g., employee, community member, etc.)

EMS Agency Information

Agency name

Agency contact first name

Middle Initial

Last name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Position

Award being nominated for (Check only one)

Private EMS Service of the Year

Municipal EMS Service of the Year

Fire/EMS Service of the Year

Industrial EMS Service of the Year

______________________________________

Nominator Information

First Name

Middle Initial

Last Name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

EMS Employer

EMS Position/Title

______________________________________

Questionnaire

Describe the impact that the agency has had on the EMS profession while serving in the role that is related to the awards for which you are nominating them. Be as specific as possible.

Describe any characteristics of the agency that have distinguished them from their peers.

How many years has the agency been involved in providing EMS services related to the award for which you are nominating them? Select the appropriate range.

Involvement in EMS-related Organizations

Local, state, and national level EMS-related organization agency belongs or has belonged to, and leadership level attained by the agency. List the date(s), name(s) of the organization(s), the agency belongs to, rank attained (member, officer, Board of Directors)

Organization Name 1

Years Involved

Activities in the organization. Be sure to include offices held and dates wherever possible.

Person Who Can Verify Involvement

Phone

__________________________________________________________________

Organization Name 2

Years Involved

Activities in the organization. Be sure to include offices held and dates wherever possible.

Person Who Can Verify Involvement

Phone

__________________________________________________________________

Organization Name 3

Years Involved

Activities in the organization. Be sure to include offices held and dates wherever possible.

Person Who Can Verify Involvement

Phone

__________________________________________________________________

EMS Related Awards

Award Title

Award Organization

Year Awarded

Award Title

Award Organization

Year Awarded

Award Title

Award Organization

Year Awarded

Award Title

Award Organization

Year Awarded

__________________________________________________________________

Support of this Nomination

Please list any other people that are joining you in submitting this nomination. Make sure they have agreed to be contacted by the Awards Committee before including them on this application.

Name

Phone

Name

Phone

Name

Phone

Name

Phone

___________________________________________________________________

Feel free to attach letters of support to this application.

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