2024 WEMSA Excellence in Service Awards Nomination Form

2024 WEMSA Excellence in Service Awards Nomination Form

Nominations must be submitted by October 31st, 2024!
WEMSA's Annual Excellence in Service Awards is a way for WEMSA to honor both individuals and organizations who have made a significant contribution to the EMS profession in the past year. Please refer to the WEMSA website for all eligibility requirements per award. Failure to meet all requirements will result in disqualification.

Review the 2024 Award Criteria

Review the 2024 Policies & Procedures
Select the Award for which you are submitting*
Does the nominee know this nomination has been submitted or would you prefer it to be kept confidential until winners are announced?*

The Nominee knows they are being nominated.The Nominee does not know they are being nominated. Please keep confidential.
Nominees Contact Information
Nominee's Name*

First NameLast Name
Nominee's Email*
example@example.com
Nominee's Phone Number*
Please enter a valid phone number.
Nominee's Current EMS Agency/ Employer*
Nominee's Employer's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Contact Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Your Current EMS Agency/ Employer*
Agency's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor/ Chief's Information

As part of the vetting process we will contact the nominee's Supervisor/ Chief. Please enter the Supervisor/ Chief's contact information. If you, the individual submitting the nomination is the nominee's Supervisor/ Chief, please re-enter your information.
Supervisor's Name*

First NameLast Name
Supervisor's Email*
example@example.com
How does the Nominee's Chief prefer to be contacted?*

EmailPhoneUnsure
Secondary Reference's Information

As part of the vetting process we will contact a secondary reference to support the nomination. Please enter a secondary reference's contact information.
Secondary Reference's Name*

First NameLast Name
Secondary Reference's Email*
example@example.com
Supervisor's Phone Number*
Please enter a valid phone number.
Secondary Reference's Number*
Please enter a valid phone number.
How does the Secondary Reference prefer to be contacted?*

EmailPhoneUnsure
Supporting Documentation

You will be required to submit a nomination statement along with this form for the nomination to be complete. To support your nomination, you may also attach up to 3 Supporting Documents, but these are not necessary for completion of the nomination.
Attach your nomination statement- 1,000 words or less (see award criteria on the WEMSA website for what should be included on your statement)*

Cancelof
Supporting Document #1

Cancelof
Supporting Document #2

Cancelof
Supporting Document #3

Cancelof
Local Media Contacts to whom press releases should be sent
Publication Name
Reporter's Name
Media Agency's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agency or Reporter's Email
example@example.com
Should be Empty:

2024 WEMSA Excellence in Service Awards Nomination Form

Nominees Contact Information

Your Contact Information

Supervisor/ Chief's Information

Secondary Reference's Information

Supporting Documentation

Local Media Contacts to whom press releases should be sent