Nomination Form

Deadline for submission: 30 September 2009
N.B. NO PERSON MAY NOMINATE HIM/HERSELF
Fields with a * are mandatory.

NOMINEE'S DETAILS
*Name of nominee
(individual or organisation)
Gender
Date of Birth (dd/mm/yyyy)
Place of Birth
Occupational Title
Institution
Address
Zip code
Country
Office Telephone
Private Telephone
*E-mail address
Personal website
Nationality
*Summary of environmental achievements (maximum 500 words)
All nominations will be considered based on the summary. Nominators of short-listed candidates will be contacted and asked to provide further details of the nominees work along with substantiating material, including a curriculum vitae, further references and details of publications, awards etc.
   
Referee 1.
Name (First,Last)*  
Address:  
Telephone:  
E-mail*:  
Profession:
Date: (dd/mm/yyyy)
 
Referee 2.
Name (First,Last)  
Address:  
Telephone:  
E-mail:  
Profession:  
Date: (dd/mm/yyyy)
 
Referee 3.
Name (First,Last)  
Address:  
Telephone:  
E-mail:  
Profession:  
Date: (dd/mm/yyyy)
 
NOMINATOR'S DETAILS
*Your First Name
*Your Last Name
Occupational Title
Organization
Address
Zip Code
Country
*E-mail Address
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