2019 Northern Virginia EMS Council Award Nomination For

Pre-hospital Provider Award

This is an offical nomination form for a regional EMS award. Please consider all the following information before you complete the form.

o        Has the nominee met all of the criteria for this award category? If not, please consider another category. Nominees that are incorrectly categorized will not be considered.

o        Do you have supporting materials if the category requires them? Supporting materials should be emailed to northern@vaems.org after you submit this form

o        You will need a high resolution digital photo of the nominee. Photo must be emailed to northern@vaems.org after you complete this form 

o        Will you meet the required deadline for entries?

o        Supporting materials and Photos can be sent after this form is completed.

 

Please fill out the following information below.

CRITERIA: An individual who exemplifies outstanding dedication and service to his or her community through involvement with EMS.

 

ELIGIBILITY: Any individual who routinely provides pre-hospital care, primarily in Virginia, is affiliated with at least one Virginia licensed EMS agency and who is certified as a pre-hospital EMS provider by the Commonwealth of Virginia.

Nominee's Information

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Your Information

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