THE NUKIYAMA MEMORIAL AWARD NOMINATION FORM_____________Date

TO THE BOARD OF THE NUKIYAMA MEMORIAL AWARD:

We, the five sponsors listed below, submit this proposal to nominate the following professional
for the Nukiyama Memorial Award.
Name_________________________________________________________________________
Current Position, Title ________________________________________________________________
Organization________________________________________________________________Address________________________________________________________________________________________________________________________________
Fax_______________________________________________________
E-mail_______________________________________________________Date of Birth______________________________

Nomination Initiated and Sponsored by:
1.

NameAddress
Fax
E-mail__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Other Sponsors of the Nomination:
2. NameAddress
Fax
E-mail
3. NameAddress
Fax
E-mail__________________________________________________________________________________________________________________________________________________________________

4. Name________________________________
Address ________________________________________________________________________________________________
Fax________________________________
E-mail___________________________________________________________________________________________________________________________________________________________________________________________________

5. Name________________________________
Address ________________________________________________________________________________________________
Fax________________________________
E-mail___________________________________________________________
Signature of the Initiator

Five reference letters from sponsors of at least two different countries who are familiar with the contributions of the nominee arerequested.
A reference letter from each sponsor should contain the following information:-Basis of sponsor's knowledge of nominee's qualifications-Specific professional contributions made by the nominee to yield a deeper insight into the relevant phenomena or to yieldsignificant technological advances-The reason for their value, and specific contributions

Professional Record of _________________________________________________(name of nominee)Date ofEach Item
FromMo. Yr.

ToMo. Yr.

Give in Sequence and Complete Detail
Brief but specific description of outstanding professional and engineering
contributions through research, teaching and design.
Information regarding each item need not be confined to one space. A
supplementary sheet may be appended if this page is inadequate, or you may
generate this sheet on your computer with appropriate space requirement.

PROFESSIONAL DATA OF NOMINEE
Education
College/University
DegreeDateSubject________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Membership in Technical/Professional Organizations__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Publications (List here two most important publications and attach a detailed list of publications
that includes title and full citation)__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Books (Titles, Publishers and Dates)__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Patents (Subjects, Serial Numbers and Dates)__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Honors and Awards________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Areas of Specialty______________________________________________________________________________
Brief description of nominee's outstanding accomplishments for citation on the plaque andcertificate (60 words or less).
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________NOMINEE'S BIODATA FOR THE AWARD BROCHURE(limited to 500 words or less)(Optional at the time of nomination, but must be finished by the initiator if the nominee isselected as an Award recipient.)