SERMACS
Regional Industrial Innovation Award

Nomination Form

Deadline: August 15, 2017

Directions: Any individual, except a member of the award selection committee, may nominate or support onlyone nominee for this award in any given year.

Submittal process: The nomination packet consists of this form and two letters of support. Submit all documents to Markus Etzkorn at .

Purpose:: This award celebrates successful innovations of industrial chemists and chemical engineers that contribute to the health of their local and regional economy and the corporate leadership for its advancement of a healthy economy. Awards are given to individuals and teams whose creative innovations have contributed to the commercial success of their company and, consequently, to the good of the community and society.

Nominator Information

Name:
Company or Institutional Affiliation:
Present Position (Exact Title):
Address:
City:
State and Zip:
Telephone:
Fax (optional):
e-mail:
Relationship to Nominee

Nominator Recommendation

Please submit a narrative statement of no more than 750 words evaluating the nominee’s industrial innovations. Explain why the nominee is being recommended for this award with regard to the stated purposes of the award, particularly creative innovations that have contributed to the commercial success of their company and, consequently, to the good of the community and society.You may type or paste your narrative below (it will continue on the next page) or you may attach the narrative as a separate document.

Nominee Information

This is an individual nomination

This is a team nomination. Please submit a separate form for each nominee

Local Section of Nominee:
Name:
Present Position (Exact Title):
Company or Institutional Affiliation:
Address:
City:
State and Zip:
Telephone:
Fax (optional):
e-mail:
Website URL (optional):

Has this nomination been discussed with the nominee(s)? Yes No

Nominee Biographical Sketch

In the space below, paste the nominee’s brief biographical sketch (and/or attach the nominee’s curriculum vitae as a separate document). Please limit biographical sketch to 500 words.

Support Letters

Letters of support with a 400 word maximum are being requested from the following references (no more than two will be accepted). These individuals should be instructed to send their letters to Markus Etzkorn at . with a deadline of August 15, 2017.

Reference name:

Reference e-mail:

Reference telephone:

Reference name:

Reference e-mail:

Reference telephone: