Nomination SubmissionRemark: Self nomination is not accepted. PhoneI. NOMINEE Name of institution (s) or individual (s) with title, position 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 NOMINATIONPlease 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 AWARDS AND HONOURS RECEIVEDVI. EDUCATIONAL BACKGROUND EDUCATIONAL BACKGROUNDVII. 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) Add Files NotePlease 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.