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Nomination Form
The AAPAM Gold medal Award will be given during the 44thRoundtable Conference in the Kingdom of Eswatini. Kindly note that: 1) A nominator is a public institution/agency/ department/institution of higher learning or any other public/civil organization). 2)ALL sections should be filled hence incomplete forms shall not be considered. 3)ALL the nominations MUST be submitted through the office of the Head of Public/Civil Service or Permanent/Principal Secretaries or Presidents/Vice-Chancellors of Universities or Heads of Municipal and Local Governments or other selected representatives of the public sector.
Nominee’s Contact Information
Salutation
*
Please Select
Mr.
Mrs.
Ms.
Dr.
Prof.
Name
*
First Name
Last Name
Job Title:
*
Department:
Organization:
*
Country:
*
Number of years in the Current Organization
*
Mailing Address
Address of the Organization:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address of the Individual’s:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work telephone Number:
Please enter a valid phone number.
Mobile/WhatsApp Number:
Please enter a valid phone number.
Email
*
example@example.com
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Section III: Nominator’s Details
This section is to be filled by the office of either Head of Public/Civil Service or Permanent /Principal Secretaries or Presidents/Vice-Chancellors of Universities or Heads of Municipal and Local Governments or other selected representatives of the public sector depending on the nominating organization.
Salutation
*
Please Select
Mr.
Mrs.
Ms.
Dr.
Prof.
Name of Organization/ Institution:
*
Country:
*
Office (Tick As appropriate):
*
Head of Public Service
Head of Public Service Permanent /Principal Secretaries
Presidents/Vice-Chancellors of Universities Heads of Municipal and Local Governments
other selected representatives of the public sector
If, other selected representatives of the public sector (Specify)
*
Authorizing Person Title
*
Name
*
First Name
Last Name
Designation
Department
*
Signature
*
Date
*
-
Month
-
Day
Year
Date
Mailing address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work Telephone:
Please enter a valid phone number.
Mobile/WhatsApp Number:
*
Please enter a valid phone number.
Email
*
example@example.com
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Next
Section III: Referees
This section is to be filled by individuals supporting the nominee’s nomination. They can be his/her colleagues, supervisors, mentors or any other persons who attest to the nominee’s academic, professional or in any other qualification.
1st Referee Contact Information
Salutation
*
Please Select
Mr.
Mrs.
Ms.
Dr.
Prof.
Name
*
First Name
Last Name
Job Title:
*
Department:
Organization:
*
Country:
*
Relation to the Nominee:
*
Mailing Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work Phone:
Please enter a valid phone number.
Mobile:
*
Please enter a valid phone number.
Email
*
example@example.com
Signature
*
2nd Referee Contact Information
Salutation
*
Please Select
Mr.
Mrs.
Ms.
Dr.
Prof.
Name
*
First Name
Last Name
Job Title:
*
Department:
Organization:
*
Country
*
Relation to the Nominee:
*
Mailing Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work Phone:
*
Please enter a valid phone number.
Mobile:
*
Please enter a valid phone number.
Email
*
example@example.com
Signature
*
3rd Referee Contact Information
Salutation
*
Please Select
Mr.
Mrs.
Ms.
Dr.
Prof.
Name
*
First Name
Last Name
Job Title:
*
Department:
Organization:
*
Country
*
Relation to the Nominee:
*
Mailing Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work Phone:
Please enter a valid phone number.
Mobile:
*
Please enter a valid phone number.
Email
*
example@example.com
Signature
*
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Section IV:
Work and Achievements of the Nominee
A) Work and Achievements
In not more than 1000 words describe the work and achievements of the nominee which in the opinion of the nominators qualifies the nominee for the Award. Kindly attach all the supporting evidence you may wish the judges to consider.
*
0/1000
B) Published Work (Starting with latest)
List the published work by the Nominee giving the title, year of publication and publishing firm including co-author where publications were co-authored.
*
C) Other Awards given to the Nominee
Presidential Accolade
Please Select
YES
NO
If yes, kindly specify the award and year
Any other Awards (specify the award and year)
Attach a detailed CV and passport size picture of the Nominee
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