PEMS Regional EMS Award for Excellence in EMS Nomination Form

Criteria for this award: 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 for this award: Any individual engaged in emergency medical services.

Name of Nominee:*

Address of Nominee:*

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip Code

Nominee Phone:*

Area Code

Phone Number

Nominee E-mail:*

Nominee Agency or Organization:*

Nominee Certification/License Number:

Nominee Position

Years of Service

Submitter Information

Submitted by:*

Submitter E-mail:*

Submitter Phone:*

Area Code

Phone Number

Brief Abstract of Nominee:

How has this person/program/agency exemplified outstanding dedication and service to the statewide Virginia emergency medical services system?*

Why is this nominee exceptionally qualified for this award?*

How has this person/program/agency demonstrated a commitment to a comprehensive, integrated system of emergency medical services throughout the Commonwealth?*

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:

Resume/CV:

Other supporting documents (newspaper/periodical articles, press releases, etc.)

Ready to submit?

PEMS Regional EMS Award for Excellence in EMS Nomination Form

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