I. NOMINEE Name of institution (s) or individual (s) with title, postion and affiliation. *
II. MAILING ADDRESS
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Address
City
Country
Postal Code
Phone
Fax
e-Mail
Other
III. STATEMENT OF THE NATURE OF THE WORK AND ITS RELEVANCE TO THE OBJECTIVES OF THE AWARD
IV. JUSTIFICATION FOR NOMINATION Give objective evidence of the impact of the medical research, health service to a large number of people
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
Note 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. Please send not more than two letters of references, that could add more information and justification for the nomination, along with the nomination. 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.