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Prince Mahidol Award Nomination Form

  1. Please fill out the form completely and accurately. If you don't fill the required blanks, there will be an error message telling what you need to fill.
  2. After you fill out the form completely and submit your information, you will see the information that you have had submitted. Please print it out, sign your name, attach other required documents and send to the address that will be shown when you have had submitted.
  3. Nomination shall be submitted by 31 May.

I. NOMINEE
Name of institution (s) or individual (s) with title, postion and affiliation. *
II. MAILING ADDRESS
Please check the box Office Home
Address
City
Country
Postal Code
Phone
Fax
e-Mail
Other
III. JUSTIFICATION FOR NOMINATION
III.1 Has the awardee made a scientific contribution of internationally recognized standards which has been shown to be of important benefits to a large number of the people of the world, transcending notional boundary?
III.2 Has the awardee made successfully an application of a body of scientific knowledge to the benefits of a large number of the people of the world, transcending national boundary?
IV. STATEMENT IN SUPPORT OF NOMINATION Please provide details of the best or the most significant contribution of the candidate.
IV.1 Give objective evidence of the impact of the medical research, health research or health service to a large number of people.
IV.2 Would you care to give the name of other worthy candidate in the same field as the nominee? (optional)
V. AWARDS AND HONOURS RECEIVED
VI. EDUCATIONAL BACKGROUND
VII. POSITIONS OCCUPIED
List the present position (s) and the previous position (s) with dates and durations together with names and addresses of employers.
VIII. PUBLICATIONS
List all important publications. Submit reprints or copies of important ones (not more than five). Attach English abstracts or English translation in case publications are not in English.
IX. NOMINATED BY
Last name
First name
Middle initial
Title
Position
Address
City
Country
Postal Code
Phone
Fax
e-Mail
Other
X. Attachment
Attachment File (PDF or ZIP)

Note

  1. Please give full information on the category III & IV. Well prepared statements which are verifiable will be of value to the nominees and to the selection commitees.
  2. Please send not more than two letters of references, that could add more information and justification for the nomination, along with the nomination.
  3. In case the nominee is an institution, please attach documents on the history, status and key officials of the institution (s). Use additional paper for each category for information as necessary.


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Prince Mahidol Award Foundation under the Royal Patronage
2nd Floor, Mahidol-Bumpen Building, Siriraj Hospital 2 Prannok Road, Bangkoknoi, Bangkok 10700 Thailand
Phone: +662-418-2568, 418-0917, 418-0220, 418-8615 Fax: +662-412-9717
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