[**National Medal of Technology and Innovation**\
]{.smallcaps}**2009 Nomination Form**

**(Nominations must be submitted by COB 5:00 p.m. EST May 29, 2009 to
NMTI@uspto.gov)**

**INSTRUCTIONS:  To enter information onto the form, click inside the
blank box and begin typing.**

I.  **General Information**

**NOMINATION FOR INDIVIDUAL**

Is this individual a U.S. citizen? (U.S. Citizenship is a requirement.)
Yes No

NAME TITLE

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  Pronunciation                       
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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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**NOMINATION FOR TEAM (Up to four Individuals)**

Are members of this team U.S. citizens? (U.S. Citizenship is a
requirement.) Yes No

**NAME #1 TITLE**

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  Pronunciation                       
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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 #2 TITLE

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  Pronunciation                       
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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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  Pronunciation                       
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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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  Pronunciation                       
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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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**NOMINATION FOR COMPANY/ORGANIZATION (OR DIVISION THEREOF)**

Is company/organization over 50% owned by U.S. citizens? Yes No

NAME (Representative) TITLE

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  Pronunciation                       
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COMPANY / ORGANIZATION

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  Pronunciation                   
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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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PAST MEDAL RECIPIENT(S) WITHIN THE COMPANY/ORGANIZATION

NAME(S) AWARD YEAR CONTRIBUTION/ACHIEVEMENT

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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.uspto.gov/nmti.

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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**

Is nominee being nominated for the same achievement to the National
Medal of Science? Yes No

Has the nominee been a recipient of the National Medal of Science or the
National Medal of Technology and Innovation? Yes No

If yes, clearly differentiate the work that distinguishes this
nomination from the work that was the basis for the earlier award.

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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.

For individual or team, if this is a self-nomination, check this box and
proceed to Section V.

For nomination of a company/organization, complete the information below
before proceeding 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) or as a PDF file. Please label each letter
    with last name of nominee, underscore, first name, underscore, the
    word "rec" and last name of person writing support letter.doc.

> For example: Doe_John_recSmith.doc.

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

-   Alternatively, letters of recommendation may be sent by **e-mail**
    to <NMTI@uspto.gov>, **fax** to (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)
    272-8600. **Letters of recommendation must arrive by close of
    business (5:00 p.m. EST), May 29, 2009.**

Please complete contact information for letters of recommendation or
support. A confirmation 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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**RECOMMENDATION #7**

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 #8**

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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For additional letters of recommendation, please provide the above
requested information on a Word document and submit it with this
application.

**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 Science and Technology Medals 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 40 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 United States Patent and Trademark Office, P.O. Box 1450,
Alexandria, VA 22313-1450 (<NMTI@uspto.gov>).