Prince Mahidol Award Logo
Prince Mahidol Award
Nomination Form
Strictly Confidential
Instruction

  1. Please fill out the form completely and accurately. If you don't fill the required blanks, there will be an error message telling what you need to fill.
  2. After you fill out the form completely and submit your information, you will see the information that you have had submitted. Please print it out, sign your name, attach other required documents and send to the address that will be shown when you have had submitted.

I. NOMINEE
Name of institution (s) or individual (s) with title, postion and affiliation. *

II. MAILING ADDRESS
Please check the box
Office Home
Address
City Country Postal Code
Phone
Fax E-mail
Other

III. STATEMENT OF THE NATURE OF THE WORK AND ITS RELEVANCE TO THE OBJECTIVES OF THE AWARD

IV. JUSTIFICATION FOR NOMINATION
Give objective evidence of the impact of the medical research, health service to a large number of people

V. AWARDS AND HONOURS RECEIVED

VI. EDUCATIONAL BACKGROUND

VII. POSITIONS OCCUPIED
List the present position (s) and the previous position (s) with dates and durations together with names and addresses of employers.

VIII. PUBLICATIONS
List all important publications.
Submit reprints or copies of important ones (not more than five). Attach English abstracts or English translation in case publications are not in English.

IX. NOMINATED BY
Last name First name Middle initial
Title
Position
Address
City Country Postal Code
Phone Fax E-mail
Other

Date Month Year


Note

  1. Please give full information on the category III & IV. Well prepared statements which are verifiable will be of value to the nominees and to the selection commitees.
  2. Please send not more than two letters of references, that could add more information and justification for the nomination, along with the nomination.
  3. In case the nominee is an institution, please attach documents on the history, status and key officials of the institution (s). Use additional paper for each category for information as necessary.

Please press the button to your information.