RSNZ:

NOMINATION FORM

New Zealand Science & Technology Medals

I nominate...

Name
Address
Position
Institutional affiliation
Phone
E-mail

for a New Zealand Science & Technology Medal

My details are...

Name
Address
E-mail
Affiliation*
Position
Phone
Relationship to nominee
Seconder(s) name
Seconder(s) address
Affiliation*
Exec. Position
Date

*Constituent organisation, regional constituent organisation, or affiliate organisation of the Royal Society of New Zealand.

Please include:

A CV of the nominee

A statement giving details of the relevant contributions the nominee has made to science and technology both in the field and to the wider community

A brief statement (not above 100 words) giving reasons why the nominee should be awarded the medal. The statement should be in a form that can be used in publicity

A brief citation (not above 40 words) for use on award documents

The names, addresses, phone numbers (and e-mail addresses if available) of three referees who could be approached for reports on the nominee's suitability for the award