Please complete the following information about the nominee. (Please fill out this form completely as it ensures that all appropriate information is included).

Nominee Name
Position/Title
Company
Address
Address 2
City
State Zip

Synopsis of OHN Responsibilities

Professional Associated affiliations (describe role in association(s), office, committees, Chairmanships, etc.)

INITIATIVE

PRODUCTIVITY

MOTIVATION

CREATIVITY

COMMITMENT

Nominated By
Position/Title
Address
Address 2
City
State Zip
Phone Ext.
Fax
E-Mail

Please note: Medique Products does not choose Medique Award Winners. That responsibility lies with each state's OHN award committee. All nominations received will be forwarded to the appropriate committee as quickly as possible. In order to expidite this process, please provide as much information as possible below.

State OHN
Chairperson Name
Chairperson E-mail