Patriot Medal Nomination Summary: The Patriot Medal is awarded only by a state society and may be presented only to an individual. It represents long, faithful and outstanding service at the state and/or chapter level. Service at the national level is not considered in making the award. It is desirable that it be presented at the annual meeting of the state society. A representative cannot accept the Patriot Medal. • All requirements should be thoroughly reviewed before requesting this medal. The Executive Director maintains a record of all past recipients so that societies may contact him in advance to determine if a person has already received the medal and thus avoid an invalid request. • Application must be made to the Executive Director on a standard form at least thirty (30) days before the medal is to be presented. Include with the application, payment for the current cost of the medal, signature of the state society president and complete supporting evidence. • The Patriot Medal may be awarded annually by any state society. State societies with fewer than 500 members may present no more than one medal each calendar year. State societies with 500 to 1000 members may present two medals each calendar year. State societies with over 1000 members may present one medal for each 500 members. • A Compatriot may receive this medal only once. Oak leaf clusters or other ribbon attachments are not authorized.

Nominee Name: Society:

National Number: State Number: Date of Admission: Record of service to the Society (to be completed by an officer of the nominating Society)

Service to Chapter and/or Society organization

(use additional pages if required)

Record of exceptional services rendered

(use additional pages if required)

Nominated by Society Name of Nominator Chapter Name: (if nominated by a Chapter):

Email: Telephone:

Nominated by Society:

Patriot Medal Committee Date: Chairman (signature):

Society President Date: (signature):

Society Secretary Date: (signature):

Form PM ver. 1 2016