Extra Mile Awards Nomination Form

You can use this form to submit your Extra Mile Awards nomination online. Nominations can be made at any time.

Please note: Nominees for these awards should be working in England, Wales or Northern Ireland only.

* denotes a required field Your Name House name/number Street Town County Postcode Telephone Email Date: I would like to nominate Job title Name of Hospital/Primary Care Trust/Social Services Address of Hospital/Primary Care Trust/Social Services Tell us how this person has gone the extra mile for you. Do you want to be involved in the presentation of this award? Yes No