Nominate A Nurse

Nominations Deadline: MARCH 22, 2013

Please note that nominations will not be accepted after the March 22rd deadline.

Criteria for Nomination:

Registered Nurses, Licensed Practical Nurses, Advanced Practice Registered Nurses and Nurse Practitioners may be nominated for recognition by their employers if they are involved in clinical practice, leadership, scholarship and/or education.

Nominees should have:
• Made a significant impact on patient care and/or the nursing profession;
• Gone "beyond the call" in a clearly illustrated scenario;
• Demonstrated excellence above what is normally expected;
• Shown commitment to the community served in a way that is significantly above the norm; or
• Achieved a life-long legacy in a particular arena.

Nightingale nominations are accepted from health care organizations only.

Please complete the fields below and submit with the fee of $100 per nomination.

**Nominee Photo must be emailed to Donna Blackstone in a jpeg format by March 22, 2013.

Billing Information *PLEASE NOTE - This page will time out after 15 minutes of inactivity, it would be best to prepare your narrative before filling out the form to avoid any loss of input. Note - If you are paying online, please be sure to enter your billing address for the card you are using for payment. Thank you!
Nominating Organization
Contact Person
Street Address
City State, Zip	,
Phone Number
Fax Number
Email Address
Nominee Information
Nominee Name
Credentials
Phonetic Spelling
Supervisor of Nominee
Home Address
City State, Zip	,
Phone Number
Email Address
Nominee Photo must be emailed to Donna Blackstone in a jpeg format by March 23, 2013. Please complete this form and submit with the $100 per nomination.
Every nurse is caring and committed to his or her patients, students, co-workers, etc. In 300 words or less, please tell us what sets this nurse apart from other caring nurses. To be considered for the award, specific examples and information clearly relating to the Criteria for Nomination list must be cited.
Nomination Narrative You may cut and paste from Word (limit 300 words please) ***PLEASE NOTE - This page will time out after 15 minutes of inactivity, it would be best to prepare your narrative before filling out the form to avoid any loss of input.
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