AEMP Long Form

Nominee Name*

First Last

Phone*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Organization

Supervisor

Check all that apply:

The candidate displays the highest level of integrity, honesty and respect for others.
The candidate exemplifies the organization’s code of ethics
The candidate is involved in civic organizations and endeavors. (please list)

Civic Organizations and Endevors

Education & Experience

Years in profession

Years with organization

Years in current position

Highest level of education obtained

Certifications earned (please list)

Continuing education completed (please list)

Please provide a summary of the candidate’s accomplishments in each category below.

Occupational/Environmental Safety

The ideal candidate displays appropriate personal protection techniques at all times, assists others in proper safety techniques and complies with all applicable governmental regulations (OSHA, MSA, etc).The ideal candidate makes recommendations for improving safety, follows employer safety policies and complies with all EPA, DEP, and state/local regulations.

Use of Technology

The ideal candidate effectively utilizes available technology on the job, encourages use of new technology and stays informed of emerging technologies.The ideal candidate is willing to use personal resources to expand their skills and encourages others to embrace new technology.

Technical Proficiency

The ideal candidate displays mastery of all job-related functions, exceeds the quality standards expected by the organization and effectively manages time spent on the job. The ideal candidate shows the ability to perform duties unsupervised and is willing to mentor others.

Innovation & Initiative

The ideal candidate has created processes, tools and/or techniques that have improved efficiency, safety or some other aspect of the job.The ideal candidate suggests ways to improveefficiency, safety, and operations of the organization; finds creative ways to solve existing problems; and proactively finds ways to prevent problems from occurring. The ideal candidate encourages others to be innovative, takes ownership of decisions and is fully engaged in their role and responsibility in the organization.

Employee &Vendor Relationships

The ideal candidate provides suggestions and positive input in employee meetings and to immediate supervisor, understands and adheres to organizational policies and procedures, and understands and respects chain of command.The ideal candidate understands and is committed to furthering company objectives; displays a willingness to share expertise with others; and recognizes the efforts of others, sharing them with management.The ideal candidate gets along with others, is a team player and displays a positive attitude in accepting suggestions from others.The ideal candidate displays a professional attitude and demeanor with vendors, is comfortable asking for technical guidance and effectively communicates equipment status or changes made to the equipment's operational capabilities.

For completion by Candidate*

If selected as the winner of this award, I will personally appear at the AEMP Annual Meeting. For more information on the Annual Meeting, visit www.aemp.org

Digital Signature, please complete with full name

Title

Phone

Email

For completion by Supervisor and/or Owner*

I hereby certify, that the information contained in this Nomination Form is true and accurate to the best of my knowledge.

Supervisor name and title

Phone

Email

Relationship to candidate

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