Self Nomination

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NOMINEE’S PERSONAL DETAILS
Name*
Prefix First Last
Gender*
Year of Birth*
Year of Birth (format: yyyy)
Please enter a number greater than or equal to 1950.
Nationality*
Country
Country of Residence*
Country
Highest Academic Degree*
specification of "Other"*
Please specify “Other”
Year of Highest Degree*
Year of Highest Degree obtained (format: yyyy)
Please enter a number greater than or equal to 1921.
* Required

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NOMINEE’S CURRENT EMPLOYMENT DETAILS
Affiliation*
Current Position*
Previous Position(s)

Previous Position(s) (max 8)
Organization Position From (year) To (year)
Main Working Language(s):*
Address current work location*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email address*
Telephone*
Nominee’s professional homepage or website:
Five most relevant publications*
Author(s) Year Titel Name of Scientific Journal
Academic Background:*
Academic Background ^*:
e.g., Subject of BSc./MSc./PhD thesis and PI positions (max 8 lines).
* Required

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Organization	Position	From (year)	To (year)

Author(s)	Year	Titel	Name of Scientific Journal

Organization	Role	From (year)	To (year)