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DISTINGUISHED ALUMNI AWARD
Graduate Studies of Mahidol University Alumni Association
2016 Nomination Form
Categories
Public Services General Integration
Academic/Research Administration
Excellent All-round
Information and achievements of Award Nominee
- Nominee Information
Given name……………………Middle name ………………Last name …………………...
(Former first name, middle name and last name if a change of name is made) ………………………………………………………………………………………………..
Date of Birth (day/month/year) ...... /……………./…..…….Age …………… Years
Nationality……………………………………………………………………………………
Occupation title ………………………………………………………………………………...
Name of Organization ………………………………………………………………………….
Number…………………………………....Street/Road ………………………………….. Sub-district ……………………………….. District ………………………………......
Province …………………………………...Postal Code…………………………………...
City…………………………………………Country……………………………………….
Telephone ………………………………….Mobile phone ………………………………..
Fax ………………………………………… E-mail address ……………………………….
Home address
Number………………………………….....Street/Road ………………………………….. Sub-district ……………………………….. District ………………………………......
Province ……………………………………Postal Code…………………………………...
City…………………………………………Country……………………………………….
Telephone ………………………………….Mobile phone ………………………………..
Fax ………………………………………… E-mail address ……………………………….
Contract address Work Home
- Educational background
2.1 Degree received from Faculty of Graduate Studies, Mahidol University
Graduate diplomaYear of enrollment …………………………………..
Major ………………………………….. Faculty …………………………………...
Year of Graduation ………………………………………………………………….
Master’s degreeYear of enrollment …………………………………..
Major ………………………………….. Faculty …………………………………...
Degree received ……………………….. Year of Graduation ………………………
Higher graduate diplomaYear of enrollment …………………………………..
Major ………………………………….. Faculty …………………………………...
Degree received ……………………….. Year of Graduation ………………………
Doctoral degreeYear of enrollment …………………………………..
Major ………………………………….. Faculty …………………………………...
Degree received ……………………….. Year of Graduation ………………………
2.2 Degrees from other institutions/universities
Degrees received / Institutions/Universities / Year of graduation1.
2.
3.
4.
5.
- Profession
Government officer and/or employee State enterprise employee
Self-employed business Private company
Other (Please specify.) ……………………………………………………………………….
Current position ……………………………………………………………………………….…
EMPLOYMENT RECORD: Begin with the most recent employment, if applicable.
Name and Address of Organization / Period of Employment / Position / Responsibility /Type of work
From To
From To
Note: If the blank spaces above are not sufficient for the information required, please insert the additional row(s).
- Information related to work
4.1.Full-time employment
4.2.Extra-activities
4.3.Member(s) or committee(s) of associations, charities, clubs, or others
4.4.Awards and recognitions received
- Please make a list of your accomplishments in compliance with the category that you wish to be considered. (Please attach important documents with this form.)
5.1 Public Services
(1) Works that demonstrate the excellence in the performance of duties
(2) Works that go beyond the call of duty, such as, volunteering and public services
that deliver the benefits at a communal, societal, or national level
(3) Works and Honours/Awardsthat have received national/international recognitions in term of PublicServices
(4) Works and Honours/Awardsthat have received national/international recognitions
aside from PublicServices
5.2 General Integration
(1) Works that demonstrate the excellence in General Integration that delivers the
benefits at a communal, societal, or national level
(2) Works and Honours/Awards that have received national/international recognitions
in term of General Integration
(3) Works and Honours/Awards that have received national/international recognitions
aside from GeneralIntegration
5.3 Academic/Research
(1) Books/textbooks
(2) Academic articles and/or academic works that have been published in academic
journals or presented in academic forum
-National level (Please specify.) …………………………………………………..
-International level (Please specify.) ……………………………………………...
(3) Inventions/innovations with registered patent
(4) Works and Honours/Awards that have received national/international recognitions
in terms of Academic/Research
(5) Works and Honours/Awards that have received national/international recognitions
aside from Academic/Research
5.4 Administration
(1) An individual who holds or held an administrative position in governmental or
private organizations or agencies
(2) Works that demonstrate the excellence in the performance at an organizational or
national level while being in the administrative position
(3) An individual who is or was in the principal administrative position for more than 2
years
(4) Works and Honours/Awards that have received national/international recognitions
in term of Administration
(5) Works and Honours/Awards that have received national/international recognitions
aside from Administration
5.5 Excellent All-round
(1) Works that demonstrate the highest level of accomplishment in terms of Public
Service, General integration, Academic/Research and Administration
(2) Works and Honours/Awards that have received national/international recognitions
in integrated areas
6. A summary of significant achievements in compliance with the category to be considered.
(Please make a list using bullet points, and not exceeding a page of an A4 paper size.)
Signed ……………………………………….. Nominee
(………….…………………………)
Date ….……../…………/………….
Nominator information
Given name………………….Middle name ………..…………Last name ………………… Position ……………………………………….……………………………………………...
Relationship to Nominee ……………………………………………………….……………
Contract address ……………………………………………………………………………..
…………………………………………………………………………………………….….
Telephone ……………………………………….. Mobile Phone ………………………….
Fax ………………………………………………. E-mail address …………………………
Signed ……………………………………….. Nominator
(………….…………………………)
Date ….……../…………/………….
Please save the file(s) containing information and works in a CD or attach the file(s) via
E-mail: