Regional EMS Award for Excellence in EMS Nomination Form

CRITERIA: An individual who exemplifies outstanding dedication and service to the statewide Virginia emergency medical services system, and has demonstrated a commitment to a comprehensive, integrated system of emergency medical services throughout the Commonwealth.

ELIGIBILITY: Any living individual, in good standing, engaged in emergency medical services within the Commonwealth of Virginia, with significant contributions at the local, regional, state and national level. Individuals should maintain a current Virginia EMS certification (where applicable) and have no outstanding or pending notices of enforcement actions taken against them.

Select Award Category*

Award for Excellence in EMS

Select Regional EMS Council*

Nominee Name*

Nominee Address*

Nominee Email*

Work Phone

Cell Phone*

Agency Affiliation*

Nominee Certification Number

Position

Nomination Submitted By*

Address

Email*

Work Phone

Cell Phone*

DOCUMENTATION SUPPORTING NOMINATION

Read each statement below carefully and answer completely. Limit documentation to the information requested. Up to three documents may be attached to the nomination form. Of these items, one letter of support written by someone other than nominator must be included. Other documents may include a resume or CV, a newspaper article written about the nominee, etc.

Supporting Documentation

Drop files here or

Max. file size: 100 MB, Max. files: 3.

1. Brief Abstract of Person being Nominated: Summarize and justify why this person should receive this award. You are encouraged to consider the following questions when providing your response to this section.*

a. How has this person exemplified outstanding dedication and service to the statewide Virginia emergency medical services system? b. Why is this nominee exceptionally qualified and selected for this award? c. How has this person demonstrated a commitment to a comprehensive, integrated system of emergency medical services throughout the Commonwealth and the Nation?

2. Success & Accomplishments in EMS: Provide a description of the successes and accomplishments of this person in EMS, to include honors, awards (civic or professional) that highlight their contribution to EMS and the community.*

Photo Required: A photo of the nominee must be included. Try to send a color photo (with good lighting) with just the nominee in it. If it is an agency or organization, the photo can be a group shot of agency members, a picture of agency headquarters or a logo.*

Accepted file types: jpg, jpeg, png, gif.FileDescription

To verify the accuracy of the information provided in this nomination form, please type your First and Last Name, along with the date that you submitted this nomination form.

Nominator's Name*

First Last

Nominator's Email

Date of Document Submission:*

Regional EMS Award for Excellence in EMS NOMINATION FORM