New Hampshire Annual Ems Awards - Nomination Application - 2016

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2016 New Hampshire Annual EMS Awards – Nomination Application
(copies of this form can be made for additional nominations)
This nomination is for the following [Please check ONE]:
[ ]
Pamela Mitchell/Richard Connolly Memorial EMS Achievement Award
[ ]
Lawrence A. Volz EMS Heroism Award
[ ]
Bound Tree Corporation EMS Unit of the Year Award
[ ]
David J. Connor Memorial EMS Appreciation Award – “The Connor Honor”
[ ]
EMS Educator of the Year Award
[ ]
David F. Dow Memorial EMS Provider of the Year Award
Name of nominee: _____________________________________________
Street Address: _______________________________________________
_______________________________________________
City: ___________________________ State: __________ Zip: _________
Telephone Number: ____________________________________________
Your Name: __________________________________________________
Street Address: _______________________________________________
_______________________________________________
City: ___________________________ State: __________ Zip: _________
Your daytime phone:____________________________________________
Your signature: __________________________________ Date: ________
***********************************************************************************************************************
Send award nominations to:
NH DOS, FST & EMS – Bureau of Emergency Medical Services
Field Services Section – Annual EMS Awards
33 Hazen Drive
Concord, NH 03305
A fax of the nomination can be sent to (603) 271-4567 but must be followed-up with mailing the
original to the Bureau of EMS.
IMPORTANT: Nominations should include details about the nominee but be limited to not more than
two typed pages of documentation. Submit newspaper clippings or coverage, if available. Digital photos of the
individual or group being nominated must be available upon request by the Committee.
►►►
◄◄◄
June 1, 2016
Nominations must be postmarked by
in order to be considered.
If you have questions concerning Awards, please contact the following :
Note DEADLINE
Kathy Higgins Doolan, Field Services Coordinator - (603) 223-4281
For Nominations
Or via email at :
kathy.doolan@dos.nh.gov

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