OMB Control Number: 2060
- NEW Expiration Date: 6/30/ 13

EPA Form # xxxx
- xxx, Revised 06/10 

# U.S. EPA MONTREAL PROTOCOL

AWARDS NOMINATION FORM

INTRODUCTION The Stratospheric Protection Division of the U.S. Environmental Protection Agency (EPA) invites nominations for the U.S. EPA Montreal Protocol Awards. This award program was established in 1990 to recognize outstanding contributions to the protection of the Earth’s stratospheric ozone layer. BACKGROUND & ORGANIZATION Since 1990 , over 500 awards have been presented to outstanding individuals and teams , dedicated companies, forward
- thinking organizations, and visionary government institutions from 54 countries. Awards are particularly prestigious because nominees compete globally against the accomplishments of many other potential awardees , and recipients are selected by previous awardees and EPA

. EPA seeks nominations for the following accomplishments: originality and public purpose; leadership and corporate responsibility; global perspective and implication; actual elimination of ozone - depleting substance emissions; success in eliminating s ubstances that deplete the ozone layer and contribute to climate change or in trans itioning to alternative s with reduced environmental impact; or leadership in improving awareness of the harmful health effects of overexposure to UV radiation. Award recipie nts are leading by example. Their demonstrated commitment and extraordinary contributions inspire other individuals and organizations to make a difference in protecting the environment and public health. Their significant contributions help mitigate the he alth and environmental risks of ozone depletion, which include skin cancer, suppression of the immune system, cataracts, and damage to marine life and crops , as well as the health and environmental risks of climate change, which include air quality problem s and damage to agricultural crops. AWARDS PANEL & SELECTION OF AWARD RECIPIENTS EPA’s Stratospheric Ozone Protection Program consults an international panel of judges about the nominations . The judges represent government, industry, and non - governm ental organizations. EPA makes the final selections. INSTRUCTIONS All nominations must include an official cover letter from the nominator, a completed application form, and a one
- page summary of accomplishments. Electronic submissions are preferred. Bec ause the judges will not be able to conduct on - site visits, applicants are encouraged to submit supporting materials such as photographs, videos, technical descriptions, news clippings, and press releases. Please note that all submissions are final, and th e application and supporting materials will not be returned. Nominations must be mailed, faxed or e mailed no later than December 3 1 . E - Mail (preferred): Vazquez.Kristinn@epa.gov Regular Mail: U.S. EPA Montreal Protocol Awards Attn: Kristinn Vazquez U .S. Environmental Protection Agency 1200 Pennsylvania Ave. NW (6205J) Wa shington, D.C. 20460, USA Express Delivery (FedEx, UPS, DHL, etc.) U.S. EPA Montreal Protocol Awards Attn: Kristinn Vazquez Stratospheric Protection Division 1310 L Street, NW , Room 1 032 Wa shington, D.C. 20005, USA QUESTIONS? For more information, visit: www.epa.gov/ozone/awards/ or contact Kristinn Vazquez at 1 (202) 343
- 9062 or by e - mail at Vazquez.Kristinn@epa.gov The public reporti ng and recordkeeping burden for this collection of infor mation is estimated to average 2. 5 hours per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pen nsylvania Ave., NW , W ashington, D.C. 20460. Include the OMB control num ber in any correspondence. Do not send the completed form to this address.OMB Control Number: 2060
- NEW Expiration Date: 6/30/ 13

EPA Form # xxxx
- xxx, Revised 06/10 

### U.S. ENVIRONMENTAL PROTEC TION AGENCY MONTREAL PROTOCOL AWARD NOMINATION AWARD CATEGORY Individual Organization/Association/Group Corporate Government Team Title of project or activity (if applicable) Approximate date project began (if applicable) Project status: (if applicable) Ongoing Complete
INFORMATION ABOUT TH E NOMINEE Name of award nominee (primary contact; include other names and info as well) Address (if company or organization, use headquarters address) City State/ Province ZIP/Postal Code Country Phone E - mail Contact ( if nominee is an organization) Contact phone Contact e - mail
INFORMATION ABOUT NO MINATOR Nominated by: Affiliation Address City State/ Province ZIP/Postal Code Country Phone E - mail
REFERENCES Please identify two independent exper ts who can verify the accomplishment(s) of the person or organization nominated for the award. Name Affiliation E - mail Phone Address Name Affiliation E - mail Phone AddressOMB Control Number: 2060
- NEW Expiration Date: 6/30/ 13

EPA Form # xxxx
- xxx, Revised 06/10 SUMMARY OF ACCOMPLIS HMENTS Please summarize the nominee’s accomp lishment in the space below, or attach a one - page summary (

no longer than 600 words).

SIGNATURE OF NOMINAT OR I certify that my answers are true and complete to the best of my knowledge. Signature Date Please note

- no signature necessary if form sent electronically from nominator’s e -mail account.OMB Control Number: 2060
- NEW Expiration Date: 6/30/ 13

EPA Form # xxxx
- xxx, Revised 06/10 

### ELIGIBILITY Candidates may be from anywhere in the world. Individuals and organizations may work for the public or private sector. Candidates may be either self- nominated or nominated by a third party.
NOMINATION PROCESS Nominations should include a standard nomination form, a cover letter from the nominating individual/organization, a one - page summary of the candidate’s accomplishments , and supp orting materials.
SELECTION CRITERIA Award recipients must demonstrate one or more of the following criteria: o originality and public purpose; o leadership and corporate responsibility; o global perspective and implication; o s uccess in eliminating substances that deplete the ozone layer and contribute to climate change or in trans itioning to alternative s with reduced environmental impact; or o leadership in improving awareness of the harmful health effects of overexposure to UV radiation . Actual (as oppo sed to anticipated) results/reductions are preferred.
JUDGING PROCESS Nominations will be screened by a panel of judges selected for their expertise. Past awardees also serve on the judging panel. EPA makes the final selection of award recipients . PRESENTATION OF AWAR DS Award recipients will be announced at the annual Awards Ceremony in the fall at a location to be determined . RECIPIENT BENEFITS Past recipients of the Award have noted their appreciation of the benefits that accompany this award . Those selected can expect to enjoy: the honor of receiving this prestigious, international environmental award; increased name recognition; improved employee morale; and personal satisfaction and affirmation of having made a real difference.