Heart of Staffordshire General Practice Awards 2026 – Honouring Long Service Step 1 of 8 12% CATEGORY 3: HONOURING LONG SERVICEPurpose: To recognise and celebrate individuals who have dedicated 25, 30, 35, 40, 45 or 50 years of service within General Practice and the wider NHS.Name (person completing this form)(Required) First Last Email (person completing this form)(Required) Your Contact Telephone Number(Required) About the NominationPlease complete the information below to begin your nomination. You do not need to complete the form in one sitting – you can save your progress at any time and return later using your unique link.Please tell us who this nomination is for:(Required) I am nominating myself I am nominating another individual Your Details (Self Nomination)Please enter your own contact details below. If you are nominating another individual or a team, you will be asked for the nominee’s details on the next page.Your Practice, Organisation or PCN(Required)Job Title(Required)Eligibility Declaration(Required) Please tick to confirm I confirm that the information provided in this nomination is accurate to the best of my knowledge and that the nominee meets the eligibility criteria for the award being nominated.Privacy Notice(Required) Please tick to confirm I have read and understood the Privacy Notice and consent to Staffordshire Training Hub processing the information contained within this nomination for the purposes of administering the Heart of Staffordshire General Practice Awards.Your Details Cont.Your Practice, Organisation or PCN(Required)Job Title(Required)Nominee DetailsPlease provide the details of the individual being nominated. The fields displayed will vary depending on the nomination type selected on the previous page.Nominee Full Name(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Nominee Email Address(Required)Nominee Contact Telephone Number(Required)Nominee Practice, Organisation or PCN(Required)Nominee Job Title(Required)Eligibility Declaration(Required) Please tick to confirm I confirm that the information provided in this nomination is accurate to the best of my knowledge and that the nominee meets the eligibility criteria for the award being nominated.Privacy Notice(Required) Please tick to confirm I have read and understood the Privacy Notice and consent to Staffordshire Training Hub processing the information contained within this nomination for the purposes of administering the Heart of Staffordshire General Practice Awards. Long Service Award CategoryPlease tell us which Long Service Award category this application is for:Service Years 25 Years 30 Years 35 Years 40 Years 45 Years 50 Years Supporting StatementPlease provide a brief overview of nominee career journey across General Practice and the wider NHS (Minimum 150 words; Maximum 300 words)(Required)Please complete all sections accurately, including any breaks in service (e.g. maternity leave, career break or sabbatical), to ensure your length of service is calculated correctly and you receive the appropriate award. Unfortunately, incomplete information may result in the nomination being ineligible. Employment HistoryPlease complete in chronological order (earliest to latest employment dates)List(Required)Place of WorkJob TitleStart Date (Month and Year)End Date (Month and Year) Add Remove Proudest AchievementsWhere possible, please include examples that you would be happy for us to use when creating the award biography for the Long Service Award commemorative booklet. Before you answer When completing your response, you may wish to consider: Memorable achievements Supporting patients or colleagues Service development Leadership opportunities Career milestones or proud moments Inspiring or mentoring others What has kept you passionate throughout your career Looking back over your career, what have been your proudest achievements, and what has inspired or motivated you to remain dedicated to General Practice and the wider NHS? (Minimum 150 words; Maximum 300 words)Photographs of NomineePlease upload one or more clear, good-quality photographs of the nominee. Where possible, photographs should be provided in their original size rather than as screenshots. Please ensure that everyone clearly identifiable in the photographs has given permission for them to be submitted and used for these purposes.File Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 25 MB, Max. files: 3. DisclaimerIf your nomination is successful, do you give the Staffordshire Training Hub permission to use the information and photographs provided for publicity purposes, including the commemorative booklet, website, social media and presentation ceremony?D you permit? Yes No Additional CommentsSharing on StageIf your nomination is successful, would you be happy to briefly share a memorable moment or highlight from your career on stage at the presentation ceremony? (If you agree to share a memorable moment on stage on the day of the presentation awards, Staffordshire Training Hub will be in touch to discuss your proposed highlight and timings).Would you be interested?(Required) Yes No Maybe (please contact me) AttendanceWhilst every effort will be made to accommodate attendance requests, Staffordshire Training Hub reserves the right to restrict the number of guests attending the Presentation Ceremony due to venue capacity or operational requirements. Please Note If you are nominating yourself, details of your attendance and guest requirements will be collected at a later stage should your nomination be shortlisted. Please look out for future comms from Staffordshire Training Hub. AttendanceWhilst every effort will be made to accommodate attendance requests, Staffordshire Training Hub reserves the right to restrict the number of guests attending the Presentation Ceremony due to venue capacity or operational requirements. Please Note Nominees will be contacted by Staffordshire Training Hub separately regarding their attendance should this nomination be shortlisted. If the nomination you are submitting is successful, would you and a guest like to attend the Heart of General Practice Awards Presentation Ceremony on Tuesday, 10 November 2026 between 1200–1630Hrs at Uttoxeter Racecourse?(Required) Yes, just me please Yes, with a guest please No thank you Guest DetailsIf you would like to invite a guest, please provide details of guest below. Name(Required) First Last Email(Required)
