I hereby nominate the following person(s) for a Victoria Prize for Science & Innovation

Title Given name(s) Surname

Title Given name(s) Surname                 

Occupation      

Organisation (if applicable)

     

Faculty/Department (if applicable)

     

Life Sciences Physical Sciences Joint nomination (please indicate other nominee and complete a separate nomination form)

     

Postal address (must remain current until 31 December 2020)Address line 1 Address line 2

           

Suburb State Postcode                 

Email (must be accessible until 31 December 2019)     

Phone (home) Phone (work) Phone (mobile)                 

Research field     

Year PhD awarded Institution/University           

No

I have attached evidence of my Australian Citizenship1

or permanent residency 1 Australian citizen, or a person who forfeited their Australian citizenship on the acquisition of another citizenship before 4 April 2002 under the now repealed Section 17 of the Australian Citizenship Act 1948, or a person who was forced to renounce their Australian citizenship under Section 18 of the Australian Citizenship Act 1948 in order to retain another citizenship or acquire another citizenship. Applicants who are not currently Australian citizens will be required to provide evidence with their applications that they have previously held Australian citizenship.

                 

Occupation       Organisation (if applicable)

     

Postal address (must remain current until 31 December 2020)

Address line 1 Address line 2           

Suburb State Postcode Country                       

Email Mobile

           

Please provide details of the two referees2 providing written support for the nomination3 Referee 1

Name Position/Organisation           

Address     

Email Phone Mobile                 

Referee 2Name Position/Organisation

           

Address     

Email Phone Mobile                 

I have advised referees to submit a referee report 2 Referees should be able to assess the nomination and should not be from the nominee’s institution.

3 Joint nominations require the submission of a nomination form for each joint nominee using the same two referees.

No

Host organisation veski website veski bulletin

Referral Please specify:       Other Please specify:      

Nominee’s statement of consent:

I, TYPE FULL NAME HERE I have read the nomination guide for the Victoria Prize for Science & Innovation and confirm that the information contained in the nomination is true and accurate. I agree that, as a condition of forwarding this nomination, I permit the release of all materials that I have submitted for the purpose of the selection process. Furthermore, I understand that in the event of an award of a Victoria Prize for Science & Innovation, a description of my achievements will be publicised.

 Please check box as confirmation Date      

Nominator’s statement of consent:I, TYPE FULL NAME HERE have read the nomination guide for the Victoria Prize for Science & Innovation and confirm that the information contained in the nomination is true and accurate. I agree that, as a condition of forwarding this nomination, I permit the release of all materials that I have submitted for the purpose of the selection process. Furthermore, I understand that in the event of an award of a Victoria Prize for Science & Innovation, a description of my achievements will be publicised.

   Please check box as confirmation Date      

A PDF of a complete nomination should be uploaded via https://www.veski.org.au/2019vicprize-nomination-upload no later than 2.00pm [AEST] Wednesday 17, July 2019 using the naming protocol: nominee surname_initial_nomform_nominator surname.