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Star Award Nomination form
Name of Agency
Contact Name
Email
Phone Number
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Address 1
Address 2
City
State
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Date of Incident
Calendar
Now
Names and titles of individuals that directly supervised, actually operated, or provided direct assistance to the operators of the AMKUS Rescue System
Brief description of the incident, explain how the nominee was assisted by the AMKUS Rescue System
Important Note
A copy of the Incident Run Report
MUST
accompany the nomination.
Confidential patient information should be deleted.
Please e-mail run report to
jennifer.lemmon@amkus.com
or mail to AMKUS Rescue Systems, Attn: Star Awards, 4201 Montdale Drive, Valparaiso, IN 46383
The information and/or photos relating to the incident may be used by AMKUS for instructional, promotional or marketing purposes. If for any reason you do not wish to release this information please indicate so in an e-mail to AMKUS at
jennifer.lemmon@amkus.com