Official Entry Form

Name of Nominee: ____________________________________________________

Address: ____________________________________________________

City: ______________________ Zip Code: ___________________

Phone Number: ______________________ County: ____________________

(with area code)

Age of Nominee: ________

Recommended By: ____________________________________________________

Post Number: ___________ District Number: ___________

How long have you been engaged as an EMS? ____________________

Present Position: (i.e. EMS I, EMS II or Paramedic)

________________________________________________________________________

(Please give name of City, Town, and/or County in which you serve)

List of previous emergency provider experience:

_____________________________________________________________________________________

(If more space is needed attach separate piece of paper)

Submit a biographical sketch, on a separate piece of paper, of the EMS nominated, including education, family, church affiliation (if any), social organizations, or other data suitable for the construction of a speech necessary in the performance of presenting the winner’s award.

OVER

What makes this candidate an outstanding EMS?

______________________________________________________________________________

(If more space is required please attach separate paper)

Has this EMS’s superior been informed of this recommendation?

Yes ______

No ______

…if so, does he concur in the recommendation?

Yes ______

No ______

If the answer to the above question is “YES” please attach a letter of recommendation from the superior officer.

Each Post winner shall have his/her entry data submitted to the District in a form of their own choosing. Each District winner shall have his/her submission prepared as outlined by the rules presented to each District Chairman. Photos, certificates, news clippings, and other items relating to the nominee’s career should be documented in Post submissions. Submission should not exceed 25 single pages in length to the District and shall not exceed 25 single pages to the Department not including the application. The Department will return all entries to the nominees. Judging will be governed by the Rules approved by District Chairman and appended to this entry form.

Attach a small photo of the person nominated.

This recommendation is submitted by:

________________________________________ From Post: ________________

The American Legion, Department of Indiana, Located in the _______ District

Please have the following people sign where needed:

Post Commander: _____________________________________

Printed Commanders Name: _________________________________________

Post Adjutant: _____________________________________

Printed Adjutants Name: _________________________________________

Post EMS Chairman: _____________________________________

Printed Post EMS Chairman’s Name: _________________________________________

American Legion

Frank Gilbert, Jr. EMS of the Year Award

1. Each post shall select a Chairman whose responsibility will be to provide the District Committee with a suitable and qualified nominee for the award.

2. Each Post shall be made available an official entry form by the Department. This form will be the only method acceptable for Posts to certify the name and accompanying documentation to the District Chairman.

3. Each District Commander shall appoint a Committee of not less than three or more than five members whose responsibility shall be to judge all applications and select one winner who shall represent that District in Department competition.

4. Each District Chairman shall set his/her own deadline for determining the District winner. However, all District winners shall be certified at Department Headquarters no later than June 2, 2008.

5. Each District winner shall be presented an appropriate plaque during prescribed ceremonies at the Department Convention.

6. Each Post sponsoring a District winner shall be presented an inscribed citation during the ceremonies at the Department Convention.

7. The name of the winner of the EMS Award shall be announced from the podium during ceremonies at the Department Convention.

8. The winner of the Department Award shall be the guest of the Department Convention Corporation at the Department Convention where minimum benefits shall include lodging for a minimum of one day. Other candidates are the responsibility of their District and/or Post.

9. A nominee for this Award must be a living, active, full-time or volunteer EMS affiliated with an emergency medical service provider (BLS or ALS) located within the State of Indiana.

10. A posthumous award is acceptable only if the nominee’s death has occurred within the dates

in which the award is being presented.

11. No District or Department winner may be certified for consideration of EMS of the Year for successive years.

12. Membership in The American Legion shall not be a requirement or consideration in qualifying any nominee for this award.

13. The nomination for this Award of any member who sits on this Committee shall not jeopardize that member’s position on this Committee. The nominee shall enjoy the same privileges and responsibilities as all other members.

14. Entry forms provided by the Department shall be used as the sole instrument of certifying a nominee and shall not be used as a basis of accumulating points toward determining winners. Final judgment shall be made from the documenting materials appearing on the 25 pages in the album.

15. The nominee must submit a current BLS/ALS State of Indiana certification.