2025 APAI Safe Worker Awards Nomination Form

Complete this entry form thoroughly and correctly with individual information. Forms must be received by APAI no later than Friday, October 10^th. This deadline will not be extended!
Every APAI producer contractor member and laydown contractor member is eligible to enter a maximum of eight individuals. All nominees will be recognized as winners.
Invoices will be sent in late December to each contractor for all nominations.
Questions? Contact APAI Director of Technical Services, Elizabeth Pastuszka, at epastuszka@asphaltindiana.org or (317) 586-7280.

First Name *

Last Name *

Email *

Nominee Information

Name *

Company *

Email Address

Position

Jacket Selection *
Choose 1

Size *
Choose 1

We are seeking stories to incorporate into the luncheon about our safe worker award winners. If your nominee has a unique story related to leading or demonstrating safety, please share here.