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Nominee Information

Multi-line address
Award being nominated for (Check only one)

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Nominator Information

Multi-line address

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Questionnaire

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)

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EMS Related Award

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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. 

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Feel free to attach letters of support to this application.

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