Star Award Nomination form

Name of Agency

Contact Name

Phone Number

Fax

Address 1

Address 2

City

State

Country

Zip

Date of Incident

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