New Form – Prince Mahidol Award Foundation

Nomination Submission

I. 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 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

AWARDS AND HONOURS RECEIVED

VI. EDUCATIONAL BACKGROUND

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)

Choose File

Note

Please give full information under Categories III & IV. Well-prepared and verifiable statements will be of value to the nominee(s) and to the selection committees.
Please submit no more than two letters of reference, which may provide additional information and justification for the nomination, together with the nomination form.
A curriculum vitae (CV) of the nominee is encouraged as part of the nomination package. If available, please provide a short CV in English, not exceeding five (5) pages, covering the past ten (10) years.
In the case where the nominee is an institution, please attach relevant documents outlining the history, status, and key officials of the institution(s). Please use additional pages for each category, as necessary.