The nomination period is now closed. Thank you.

Please fill out this form as completely and clearly as possible, as this form will be used to contact the person you have nominated. Your name will remain anonymous unless you have chosen otherwise. Please submit only one (1) nomination per form.

Eligibility: Nominees must be a RN or LPN, must hold an unrestricted license, and must practice or have practiced nursing in Northern Nevada. Candidacy for the category of Lifetime Achievement is reserved for individuals who have been a nurse for 25 years or more and who have made contributions to nursing in Northern Nevada.

Nominations are due by 5 p.m. on Friday, February 1, 2008. If you have any questions regarding the nomination process, please contact Laurel Lindstrom at (775) 328-1209.

Items marked with an * are required!
1) Please provide contact information for your nominee:

Nominee First Name:*
Nominee Last Name:*
Mailing Address:*
City:*
State:*
ZIP:*
Employer Name:*
Work Phone:*
Nursing Department or Unit:

2) Please select the category in which you wish to nominate this person:

Nomination Category*



3) Please provide your contact information.

Your Name:*
Your Phone:*
Your FAX (if applicable):
Your E-mail*:
Do you wish to remain anonymous? Yes
No
4) Tell us about your nominee.*