Nomination Form

* Indicates a required field

First Name *

Last Name *

Email *

Telephone
Country code / area code / phone number

Title

Organization *

Address

Address (Line 2)

City *

Country*

ZIP/Postal Code

Is this a self-nomination?
We do accept self-nominations.

* Indicates a required field.

I am nominating/I am * (Please check one)	A non-profit organization A for-profit organization An individual within an academic or research institution

Category *	Environment Education Young Innovator Economic Development Health Sustainable Energy other

Project Name * (Enter the name of the Project associated with the individual or organization you are nominating)


Web Site (Enter the web site for the individual or organization you are nominating)

Problem Identification * (What serious problem or challenge with broad significance does the use of technology address? Explain the context and the existing conditions that are trying to be improved or rectified by the nominee’s technology.)
Description of Technology Application *(Fully describe the technology application. What technology is being used? How is it being used? Who is responsible? Who is benefiting? What processes or systems are in place to deliver this technology application?)