PEMS Regional EMS Award for Outstanding EMS Prehospital Provider Nomination Form

Criteria for this award:  An individual who exemplifies outstanding dedication and service to his or her community through involvement with EMS.  An individual that serves as a mentor in growth and development of the EMS field.

Eligibility for this award:  Any individual who routinely provides prehospital care, primarily in Virginia, is affiliated with at least one Virginia licenses EMS agency and who is certified as a prehospital EMS provider by the Commonwealth of Virginia.

Name of Nominee:*
Nominee Agency or Organization:*
Nominee Phone:*
Nominee E-mail:*
Address of Nominee:*
Submitter Information
Submitted by:*
Submitter E-mail:*
Submitter Phone:*
Brief Abstract of Nominee:
Why is the nominee exceptionally qualified and why should they be selected for this award?*
Explain how this provider exemplifies outstanding dedication, mentorship of the field and investment to his or her community through involvement with EMS.*
Provide a description of the successes and accomplishments of this person or agency in EMS, to include honors, awards (civic or professional) that highlight their contribution to EMS and the community.*
Supporting Documents:
Upload High Resolution Photographs of Nominee:
Letters of Recommendation:
Other supporting documents (newspaper/periodical articles, press releases, etc.)
Ready to submit?

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