2015 NSW Premier’s Prizes for Science Engineering

Nomination Form: Categories 1 – 8

CATEGORY NAME(please state which category you are nominating for)

NOMINEE’S DETAILS:

Title:
Surname: / Given name:
Gender:  Male /  Female / PhD testamur date (if applicable):
NSW Resident:  Yes  No / Australian Citizen:  Yes  No
Position: / Organisation:
Section/Department:
Street Address:
Postal Address:
Email:
Day Telephone: / Mobile:
Signature: / Date:

NOMINATOR’S DETAILS:

Title:
(Name of Nominator) Surname: / Given Name:
Sex:  Male  Female
Position: / Organisation:
Section/Department:
Street Address:
Postal Address:
Email:
Day Telephone: / Mobile:
Signature: / Date:

Selection Criteria – Categories 1-8

NOMINATION – (No more than 100 words) explaining:
  • The excellence and impact of the nominee’s research including if it addresses a significant economic, environmental, health, social or technological challenge facing NSW; (Please use font size 11-12)

NOMINATIONS CLOSE FRIDAY 11 SEPTEMBER 2015
Declaration of Consent(to be completed by the Nominee)

I have read the attached nomination for the 2015 NSW Premier’s Prizes for Science & Engineeringand confirm that the information provided is true and correct. Furthermore, as the nominee I permit the release of all materials submitted on my behalf including personal information to the selection committees for the purposes of the selection process.

I understand that in the event of being awarded the 2015 NSW Premier’s Prize for Scientist of the Year, or being a winner of a category prize, this material may be used for publicity purposes.

I have read and understood the terms and conditions for entry. I accept that any failure to comply with the terms and conditions may result in my disqualification from the awards.

I agree to:

  • If required, attend a one-day media training course to assist with interview techniques and preparation for a short video profile about my work;
  • Attend the Award ceremony in October 2015 (date to be fixed) or nominate a representative who will be able to attend and accept the award on my behalf; and
  • During a one year period following the nomination, participate in activities promoting the significance of science, engineering and technology to NSW and, if requested to, participate in a maximum of three forums, selection committees, lectures, or meetings organised by the Government to provide advice on future directions in my field, for the year following the nomination.

I understand that in the event I am awarded the 2015 NSW Premier’s Prize for Scientist of the Year, I will be ruled ineligible for any category award for which I have been nominated.

Signed:…………………………………………………Date…………………………………………

Checklist

Have you…

Stated which category you are applying for?

Attached the Nomination statement,outlining your eligibility?

Completed all the relevant information?

Sent an e-copy of your full application to

Finally, where did you hear about the award?

______