King Coronation Nomination

Submission Deadline June 20th, 2024 (08:00 MTN)

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Any personal information provided in response to this nomination form is collected in accordance with the Freedom of Information and Protection of Privacy Act (the FOIP Act RSA 2000, C.F-25) and the Alberta Personal Information Protection Act (PIPA). The personal information will be used for the purpose of assessing the nominated person’s eligibility for The Kiing Charles III Coronation Medal. The information contained in this form will be disclosed to Alberta Paramedic Association and Paramedic Association of Canada volunteer members for the purpose of assessing the suitability of the nominee for this emeritus award. Should you require further information about the collection, use and disclosure of personal information, please direct your questions to the Paramedic Association of Canada at: www.paramedics.ca. NOTE: Incomplete nominations may be rejected.

Nominee Information

Name*
Address*
MM slash DD slash YYYY
Does the nominee’s regular work include distinguished practice as a: (check all that apply)
Has the nominee ever been charged and/or convicted of a criminal offence in Canada or another jurisdiction?*
At anytime has the nominee been or ever been subject of professional regulatory complaint, investigations, reviews, proceedings or been found guilty of professional misconduct or incompetence in any jurisdiction and concerning the practice of paramedicine or any other profession?*

Nominator Information

Nominator's Name*