Page 3 of 3

Youdim Family Prize for Excellence in Cancer Research

2017 Nomination Form

Please complete the form below. All items marked with an asterisk (*) are required information. For more information, please contact Netta Glebotzki ()

Sponsor Information

*Name:
*Title:
*Present Position:
*Place of Employment:
*Address:
*E-mail Address:

*Required information (all pages)

Nominee Information

*First Name:
*Last Name:
Former Name (if any):
*Academic Title:
*Present Position:
*Place of Employment:
*Employment Address:
*City:
*Country:
Postal Code:
Telephone:
*Cell Phone:
*Home Address:
*Home City:
Home Postal Code:
Home Phone:
*E-mail Address:

Nominee Information (continued)

*Date of Birth (day/month/year):
*Citizenship (only Israeli citizens are eligible):
*Country of Legal Residence:
*Type of Research (select one): / Basic Pre-Clinical
Epidemiological Clinical

*University Records of Nominee

Name and Location / Date Attended / Degree / Date Awarded

*Sponsor’s Statement

Please provide below a brief 300 word synopsis (the box will hold up to 300 words) regarding the nominee’s research and why you believe this research is prize worthy.

Click and type your sponsorship statement here, maximum of 300 words

*References

Please provide the names and addresses of the three people whose professional recommendation letters are attached to the nomination form.

Reference #1
Name:
Address:
E-mail:
Reference #2
Name:
Address:
E-mail:
Reference #3
Name:
Address:
E-mail:

*Sponsor’s Statements

By submitting this form, I hereby certify that, to the best of my knowledge:

·  The nominee is a citizen of Israel and is currently living and working in Israel.

·  The nominee is under 50 years of age as of September 1 of the nomination year.

·  This research has never been awarded a prize in Israel or overseas.

·  The nominee has not previously received the Youdim Family Prize (for any research).

Date of submission Click here to enter a date.

*Additional Instructions to the Sponsor

Please include the following with your nomination:

·  This completed form

·  An abbreviated CV detailing the nominee’s education, academic and research accomplishments, and summary of publications and presentations

·  A list of up to 20 publications relevant to the presented research

·  Three letters of recommendation from the above references

·  This application form and accompanying documents should be provided in either MS WORD or PDF formats

·  All sent files should include the nominee’s name and content. For example: gil_levy_nomination.doc; gil_levy_cv.pdf; gil_levy_recommendation1.docx; etc.

·  Submit the completed form and additional files to

Nomination Form: Youdim Family Prize for Excellence in Cancer Reserch