Nominate a Good Samaritan

Nominee Information
Nominee's Full Name:
Instructor's Full Name:
Registry Number of Instructor:
Type of Class taken:	ASHI MEDIC First Aid 24-7 EMS or 24-7 Fire
Other training:
Date Nominee was last trained/certified:
Nominator Information
Nominator's Full Name:
Company Name:
Email Address:
Mailing Address:
City, State, Zip:
Phone (with area code):
Fax:
By submitting this nomination, I confirm that this information is true and accurate to the best of my knowledge.
MEDIA INFORMATION
Name of Local TV Station:
Phone:
Name of Local Newspaper:
Phone:
DESCRIPTION OF EVENTS
Date of Incident:
Location of Incident:
Please describe the situation and actions taken by the Nominee in as much detail as possible. Please include the outcome if known:

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