Nominee must be a registered nurse, employed full or part time in Occupational Health Nursing.

No one may nominate a relative or themselves.

Past recipients of NJ Nurses of the Year Awards may not apply.

Nominations must contain full and factual explanation and justification.

Application must be received by January 15, 2010. Any application received beyond this date will be disqualified.

I. Nominee Information

*Full Name:
*Address:
*City:
*State:
*Zip Code:
*Chapter:
*AAOHN membership ID#:
*Home Phone:
Cell Phone:
*Email:

Education

Employment Information

Current Employer:
Supervisor's Name:
Address:
City:
State:
Zip:
	Full Time Part Time
Work Phone:
Work Email:

Career Summary (Including dates, places and job responsibilities)

Additional professional responsibilities (Related to Occupational & Environmental Health Nursing)

Service to the Community (please include dates)

Professional Affiliations (Include offices held, awards received and honor societies)

Original Research, professional writing and poster presentations

Additional contributions to Occupational & Environmental Health Nursing (Not covered above)

II. Nominator's Information

*Nominator's Name:
*Position:
*Address:

III. Please attach letter of Support