NOMINATION FORM
Please complete the nomination form in full and submit it with the nomination documents. 足Nominations should be submitted not later than 15 March 2012.
Nominating institution or individual Name of the nominee
CONTACT Jacobs Foundation Seefeldquai 17, P.O. Box 8034 Zurich, Switzerland Phone +41 44 388 61 02 Fax +41 44 388 61 37 award@jacobsfoundation.org www.jacobsfoundation.org
DETAILS OF THE NOMINEE
NOMINATING INSTITUTION OR INDIVIDUAL
Surname, first name, title
Surname, first name, title
Date of birth
Nationality
Exact description of position
Exact description of position
University, institution
University, institution
Address
Address
Postal code, city, country
Postal code, city, country
Phone Fax
Phone Fax
E-mail Internet
E-mail Internet Field Main research interests
Place, date, signature