**National Medal of Technology**\
**2003 Nomination Form**

**(Nominations must be submitted by May 23, 2003 to
NMT2003@ta.doc.gov)**

I.  **General Information**

**INSTRUCTIONS:  To enter information onto the form, click inside the
first blank box and begin typing. Use the down arrow key to move to the
next blank box.**

**Nomination Type:**

Individual

Team (Up to four Individuals)

Company / Organization (or Division thereof)

NAME #1 TITLE

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COMPANY / ORGANIZATION

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ADDRESS

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CITY STATE ZIP CODE

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PHONE FAX E-MAIL

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Is this company / organization more than 50% owned by U.S. citizens? Yes
No

**Please Complete Additional Forms For Team Nominations:**

NAME #2 TITLE

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COMPANY / ORGANIZATION

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ADDRESS

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CITY STATE ZIP CODE

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PHONE FAX E-MAIL

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NAME #3 TITLE

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COMPANY / ORGANIZATION

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ADDRESS

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CITY STATE ZIP CODE

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PHONE FAX E-MAIL

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NAME #4 TITLE

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COMPANY / ORGANIZATION

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ADDRESS

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CITY STATE ZIP CODE

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PHONE FAX E-MAIL

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II. **Summary of Nominee's Contribution / Achievement**

Refer to Areas of Excellence and Nomination Guidelines in the Nomination
Instructions section of this Guide as needed.

PROPOSED CITATION FOR CONTRIBUTION / ACHIEVEMENT (Limit 1-2 sentences)

See examples of past medal citations at
[www.ta.doc.gov/medal](http://www.ta.doc.gov/medal).

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EXECUTIVE SUMMARY OF CONTRIBUTION / ACHIEVEMENT (Limit 1 page / 500
words)

This description should be appropriate for public distribution, should
the nominee(s) be selected.

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COMPREHENSIVE DESCRIPTION OF CONTRIBUTION / ACHIEVEMENT (Limit 5 pages /
2,500 words)

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**Nominee Biographical Information**

SUMMARY OF AWARDS AND HONORS THE NOMINEE HAS RECEIVED (Limit 1 page /
500 words each)

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PATENTS AND PUBLICATIONS

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COPYRIGHTS AND TRADEMARKS

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FOR INDIVIDUALS OR TEAMS: EMPLOYMENT HISTORY  (No more than 10 years
required)

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FOR TEAMS: EXPLAIN THE RELATIONSHIP AMONG TEAM MEMBERS

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FOR COMPANIES / ORGANIZATIONS: PLEASE PROVIDE INSTITUTIONAL HISTORY

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III. **Nominator Information**

 

Self-nominations are accepted. If this is a self-nomination, please
check this box and proceed to Section V.

NOMINATOR'S RELATIONSHIP TO NOMINEE AND CONTRIBUTION

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NOMINATOR'S NAME TITLE

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COMPANY / ORGANIZATION

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ADDRESS

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CITY STATE ZIP CODE

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PHONE FAX E-MAIL

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V.  **Recommendations**

The nomination must include at least six letters of recommendation or
support from individuals who have first-hand knowledge of the cited
achievement(s). It is preferred that the letters of recommendation be
included with the electronic nomination file in a Microsoft Word (.doc).
If all recommendation letters are included with the electronic
nomination file, each letter must be named separately so as not to
override the file. For example: Doe_John_rec.1.doc. (rec2.doc) Please
label each letter with last name of nominee, underscore, first name,
underscore,rec1.doc. If letters of support are sent separately, label
last name, underscore, first name, underscore, and last name of person
writing support letter.doc. For example: Doe_John_recSmith.doc.

Alternatively, letters may be sent by email to **NMT2003@ta.doc.gov**,
**fax (202 501-8153), or express delivery** to the Director of the
National Medal of Technology Program, Mildred Porter, at the Technology
Administration, U. S. Department of Commerce, 1401 Constitution Avenue,
N.W., Room 4226, Washington, D.C. 20230. Phone: (202) 482-5572.
**Nominations must arrive by May 23, 2003.**

Please complete contact information for letters of recommendation or
support. A confirmation reply will be sent to those sending
recommendation letters.

**RECOMMENDATION #1**

NAME TITLE

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COMPANY / ORGANIZATION

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ADDRESS

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CITY STATE ZIP CODE

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PHONE E-MAIL

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AFFILIATION WITH NOMINEE

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**RECOMMENDATION #2**

NAME TITLE

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COMPANY / ORGANIZATION

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ADDRESS

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CITY STATE ZIP CODE

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PHONE E-MAIL

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AFFILIATION WITH NOMINEE

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**RECOMMENDATION #3**

NAME TITLE

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COMPANY / ORGANIZATION

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ADDRESS

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CITY STATE ZIP CODE

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PHONE E-MAIL

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AFFILIATION WITH NOMINEE

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**RECOMMENDATION #4**

NAME TITLE

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COMPANY / ORGANIZATION

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ADDRESS

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CITY STATE ZIP CODE

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PHONE E-MAIL

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AFFILIATION WITH NOMINEE

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**RECOMMENDATION #5**

NAME TITLE

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COMPANY / ORGANIZATION

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ADDRESS

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CITY STATE ZIP CODE

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PHONE E-MAIL

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AFFILIATION WITH NOMINEE

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**RECOMMENDATION #6**

NAME TITLE

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COMPANY / ORGANIZATION

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ADDRESS

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CITY STATE ZIP CODE

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PHONE E-MAIL

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AFFILIATION WITH NOMINEE

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**Compliance with Program Terms**

I, THE NOMINATOR(S),

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OF THE FOLLOWING NOMINEE

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for a National Medal of Technology award, by my submission of this
nomination do hereby consent to public disclosure of the information
contained in this package for the purpose of use or distribution by the
Department of Commerce to develop descriptive material, such as magazine
articles, web sites or other means, to increase public awareness of
National Medal of Technology Laureates and their accomplishments. I do
**[NOT]{.underline}** consent to public disclosure of any information
deemed personal, as noted below:

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The Department of Commerce requests that recipients of the National
Medal of Technology work with its agencies and the National Medals of
Science and Technology Foundation to share additional information about
"lessons learned" regarding U.S. commercial process and competitiveness.

The public reporting burden for the collection of this information is
estimated to average 25 hours per response, including the time for
reviewing instructions, collecting information, and completing the
form. All responses to this request for information are voluntary for
purposes of the Paperwork Reduction Act.  Please mark clearly any
portion of the information submitted that you consider to be proprietary
and it will be afforded confidentiality to the extent allowed under the
Freedom of Information Act.  Notwithstanding any other provision of law,
no person is required to respond to, nor shall a person be subject to a
penalty for failure to comply with, a collection of information subject
to the requirements of the Paperwork Reduction Act unless that
collection of information displays a current valid OMB control
number. Comments regarding the burden estimate or any other aspect of
this collection of information, including suggestions for reducing this
burden, can be sent to the Director, National Medal of Technology,
Technology Administration, U.S. Department of Commerce, 1401
Constitution Avenue, N.W., Room 4226, Washington, D.C. 20230
(NMT@ta.doc.gov).