[**National Medal of Technology and Innovation**\
]{.smallcaps}**2008 Nomination Form**

**(Nominations must be submitted by COB 5:00 p.m. EST May 30, 2008 to
NMTI@uspto.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 TITL**E

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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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III\. **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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**IV. 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) file. If all recommendation letters are
    included with the electronic nomination file, each letter must be
    named separately so as not to overwrite the file. For example:
    Doe_John_rec1.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.

-   Contact information for those sending letters of recommendation on
    the nomination form in Section V should be included in the
    nomination. A confirmation reply will be sent to those sending
    recommendation letters.

-   Alternatively, letters of recommendation may be sent by **e-mail**
    <NMTI@uspto.gov>, **fax** 571-270-9100, or **overnight delivery** to
    the National Medal of Technology and Innovation, c/o United States
    Patent and Trademark Office, P.O. Box 1450, Alexandria, VA
    22313-1450. Applicants who do not have Internet access should
    contact Jennifer Lo, Program Manager, at (571) 272-7640. **Letters
    of recommendation must arrive by close of business (5:00 p.m. EST),
    May 30, 2008.**

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 and Innovation 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 and Innovation
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 and Innovation 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 National Medal of Technology and Innovation,
c/o the United States Patent and Trademark Office, P.O. Box 1450,
Alexandria, VA 22313-1450 (<NMTI@uspto.gov>).