ࡱ> EGD bjbj 4,hh88888LLLLh$Lm:$O888'88` b"x=0m, 8,m :  AWARD NOMINATION FORM For Award Year 20__ Deadlines and descriptions of awards are listed on the AIChEWeb: HYPERLINK "http://www.aiche.org/awards"http://www.aiche.org/awards BACKGROUND DATA 1. Name of the Award: ________________________________________ Todays Date: ____________________________ 2. Name of Nominee: _________________________________________ Date of Birth: ____________________________ 3. Present Position (exact title): _________________________________ Telephone Number: (______) ________________ Company: _______________________________________________ Email: __________________________________ Street Address: __________________________________________________________________________________________ __________________________________________________________________________________________ City: ____________________________________________________ State: ____________ Zip: __________________ 4. University Education: Institution: Degree Year/Major __________________________________________ ________________ _____________________________ __________________________________________ ________________ _____________________________ __________________________________________ ________________ _____________________________ __________________________________________ ________________ _____________________________ 5. Positions Held: Company or Institution Position or Title Dates of Employment __________________________________________ _________________________ ____________________ __________________________________________ _________________________ ____________________ __________________________________________ _________________________ ____________________ __________________________________________ _________________________ ____________________ 6. Technical and Professional Society Memberships and Offices held: _________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Nominators Name, Address, Telephone Number and email: _________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Nominators Signature: __________________________________________________________________________ 7. Academic and Professional honors (include awards and prizes, membership in honorary societies and date the honor was received): ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ CITATION Proposed citation (not more than 25 carefully edited words that reflect specific achievements): ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ QUALIFICATIONS Each award has a different set of qualifications. These are described on the AIChE website, HYPERLINK "http://www.aiche.org/awards"www.aiche.org/awards. After reading them, please attach sheets providing information on the nominee. 1. Identification and evaluation of the accomplishments on which the nomination is based (maximum of two double spaced pages). 2. If the nominee has previously received any award from AIChE or one of its divisions/forums, and explicit statement of new accomplishments or work over and above those cited for the earlier award(s) must be included (max. of one double spaced page). 3. Selected bibliography (including books, patents, and major papers published). 4. Please do not include in AIChE Institute or Board of Directors Award nominations reprints or listings of invited lectures, seminars and other courses taught. SUPPORTING LETTERS Letters from no more than four individuals whose names are listed below. Awards Committee members and subcommittee members for the award may not write supporting letters. Name: ___________________________________________________ Affiliation: ___________________________________ Name: ___________________________________________________ Affiliation: ___________________________________ Name: ___________________________________________________ Affiliation: ___________________________________ Name: ___________________________________________________ Affiliation: ___________________________________ Deadlines for Division, Forum, Committee, and other awards vary. See AIChE website, HYPERLINK "http://www.aiche.org/awards"www.aiche.org/awards. 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