Nominee Information

First name

Middle Initial

Last name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Email

Phone

NREMT Number

Company name

Position

Award being nominated for (Check only one)

______________________________________

Nominator Information

First Name

Middle Initial

Last Name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Email

EMS Employer

EMS Position/Title

NREMT Number

______________________________________

Questionnaire

Describe the impact that the nominee 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 nominee that have distinguished them from their peers.

How many years has the nominee been involved in EMS in the position 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 nominee belongs or has belonged to, and leadership level attained by the nominee. List the date(s), name(s) of the organization(s), the nominee 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

Email

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

Email

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

Email

Phone

__________________________________________________________________

EMS Related Award

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

Email

Phone

Name

Email

Phone

Name

Email

Phone

Name

Email

Phone

___________________________________________________________________

Feel free to attach letters of support to this application.

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