Nomination Form

Persons may nominate themselves or their own organisation, or they may choose to nominate a third party who they believe should receive recognition. All nominations must be supported by three referees (see overleaf). Referees need not be from the candidate's home region.

Fields with a * are mandatory.

Name of nominee* (individual or organisation)
Nationality*
Date of Birth
Date of Establishment
Address
Telephone
E-mail*
Tick one:	Male Female Organisation
Nominator
Name*
Address
Telephone
Fax
Email*
Date

Area of recognition*
Please summarise in three hundred words why this nomination should be considered for the Champions of the Earth award.

Press clippings, testimonials and photographs may be sent to support the nomination. (Please do not send books, videos etc. ) Short-listed applicants will be contacted for further supporting information. Champions of the Earth Division of Communications and Public Information United Nations Environment Programme (UNEP) P.O. Box 30552, Nairobi 00100, Kenya

Referee 1.
Name (First,Last)*
Address:
Telephone:
Fax:
E-mail*:
Profession:
Date:

Referee 2.
Name (First,Last)
Address:
Telephone:
Fax:
E-mail:
Profession:
Date:

Referee 3.
Name (First,Last)
Address:
Telephone:
Fax:
E-mail:
Profession:
Date:

Partners: