National Medal of Technology and Innovation 2013 Nomination Form

National Medal of Technology and Innovation
2013 Nomination Form

(Nominations must be submitted by 5:00 p.m. ET April 1, 2013 to NMTI@uspto.gov)

INSTRUCTIONS: To enter information onto the form, click inside the blank box and begin typing.

1. General Information

NOMINATION FOR INDIVIDUAL

Is this individual a U.S. citizen? (U.S. Citizenship is a requirement.) Yes No

NAME TITLE

     	     
Pronunciation

COMPANY / ORGANIZATION

     

ADDRESS

     

CITY STATE ZIP CODE

     

     

     

PHONE FAX E-MAIL

     

     

     

NOMINATION FOR TEAM (Up to four Individuals)

Are members of this team U.S. citizens? (U.S. Citizenship is a requirement.) Yes No

NAME #1 TITLE

     	     
Pronunciation

COMPANY / ORGANIZATION

     

ADDRESS

     

CITY STATE ZIP CODE

     

     

     

PHONE FAX E-MAIL

     

     

     

NAME #2 TITLE

     	     
Pronunciation

COMPANY / ORGANIZATION

     

ADDRESS

     

CITY STATE ZIP CODE

     

     

     

PHONE FAX E-MAIL

     

     

     

NAME #3 TITLE

     	     
Pronunciation

COMPANY / ORGANIZATION

     

ADDRESS

     

CITY STATE ZIP CODE

     

     

     

PHONE FAX E-MAIL

     

     

     

NAME #4 TITLE

     	     
Pronunciation

COMPANY / ORGANIZATION

     

ADDRESS

     

CITY STATE ZIP CODE

     

     

     

PHONE FAX E-MAIL

     

     

     

NOMINATION FOR COMPANY/ORGANIZATION (OR DIVISION THEREOF)

Is company/organization over 50% owned by U.S. citizens? Yes No

NAME (Representative) TITLE

     	     
Pronunciation

COMPANY / ORGANIZATION

     
Pronunciation

ADDRESS

     

CITY STATE ZIP CODE

     

     

     

PHONE FAX E-MAIL

     

     

     

PAST MEDAL RECIPIENT(S) WITHIN THE COMPANY/ORGANIZATION

NAME(S) AWARD YEAR CONTRIBUTION/ACHIEVEMENT

     	     	     
     	     	     

2. Summary of Nominee’s Contribution/Achievement

Refer to Areas of Excellence and Nomination Guidelines in the Nomination Instructions section of this Guide as needed.

PROPOSED CITATION FOR CONTRIBUTION/ACHIEVEMENT (Limit 1-2 sentences)

See examples of past Medal citations at www.uspto.gov/nmti.

     

EXECUTIVE SUMMARY OF CONTRIBUTION/ACHIEVEMENT (Limit 1 page/500 words)

This description should be appropriate for public distribution, should the nominee(s) be selected.

     

COMPREHENSIVE DESCRIPTION OF CONTRIBUTION/ACHIEVEMENT (Limit 5 pages/2,500 words)

     

III. Nominee Biographical Information

Is nominee being nominated for the same achievement to the National Medal of Science? Yes No

Has the nominee been a recipient of the National Medal of Science or the National Medal of Technology and Innovation? Yes No

If yes, clearly differentiate the work that distinguishes this nomination from the work that was the basis for the earlier award.

     

SUMMARY OF AWARDS AND HONORS THE NOMINEE HAS RECEIVED (Limit 1 page/500 words each)

     

PATENTS AND PUBLICATIONS

     

COPYRIGHTS AND TRADEMARKS

     

FOR INDIVIDUALS OR TEAMS: EMPLOYMENT HISTORY  (No more than 10 years required)

     

FOR TEAMS: EXPLAIN THE RELATIONSHIP AMONG TEAM MEMBERS

     

FOR COMPANIES/ORGANIZATIONS: PLEASE PROVIDE INSTITUTIONAL HISTORY

     

IV. Nominator Information

Self-nominations are not accepted.

For individual or team, check this box and proceed to Section V.

For nomination of a company/organization, complete the information below before proceeding to Section V.

NOMINATOR’S RELATIONSHIP TO NOMINEE AND CONTRIBUTION

     

NOMINATOR’S NAME TITLE

     

     

COMPANY/ORGANIZATION

     

ADDRESS

     

CITY STATE ZIP CODE

     

     

     

PHONE FAX E-MAIL

     

     

     

5. Recommendations

• The nomination must include at least six letters of recommendation or support from individuals who have first-hand knowledge of the cited achievement(s). It is preferred that the letters of recommendation be included with the electronic nomination file in a Microsoft Word (.doc) or as a PDF file. Please label each letter with last name of nominee, underscore, first name, underscore, the word “rec” and last name of person writing support letter.doc.

For example: Doe_John_recSmith.doc.

• Contact information for those sending letters of recommendation should be included in the nomination form under Section V. A confirmation acknowleging receipt will be sent to those sending recommendation letters.

• Alternatively, letters of recommendation may be sent by e-mail to NMTI@uspto.gov, fax to (571) 270-9100, or overnight delivery to the National Medal of Technology and Innovation, c/o United States Patent and Trademark Office, P.O. Box 1450, Alexandria, VA 22313-1450. Applicants who do not have Internet access should contact John Palafoutas, Program Manager, at (571) 272-9821. Letters of recommendation must arrive by 5:00 p.m. ET, April 1, 2013.

Please complete contact information for letters of recommendation or support. A confirmation will be sent to those sending recommendation letters.

RECOMMENDATION #1

NAME TITLE

     

     

COMPANY/ORGANIZATION

     

ADDRESS

     

CITY STATE ZIP CODE

     

     

     

PHONE E-MAIL

     

     

AFFILIATION WITH NOMINEE

     

RECOMMENDATION #2

NAME TITLE

     

     

COMPANY/ORGANIZATION

     

ADDRESS

     

CITY STATE ZIP CODE

     

     

     

PHONE E-MAIL

     

     

AFFILIATION WITH NOMINEE

     

RECOMMENDATION #3

NAME TITLE

     

     

COMPANY/ORGANIZATION

     

ADDRESS

     

CITY STATE ZIP CODE

     

     

     

PHONE E-MAIL

     

     

AFFILIATION WITH NOMINEE

     

RECOMMENDATION #4

NAME TITLE

     

     

COMPANY/ORGANIZATION

     

ADDRESS

     

CITY STATE ZIP CODE

     

     

     

PHONE E-MAIL

     

     

AFFILIATION WITH NOMINEE

     

RECOMMENDATION #5

NAME TITLE

     

     

COMPANY/ORGANIZATION

     

ADDRESS

     

CITY STATE ZIP CODE

     

     

     

PHONE E-MAIL

     

     

AFFILIATION WITH NOMINEE

     

RECOMMENDATION #6

NAME TITLE

     

     

COMPANY/ORGANIZATION

     

ADDRESS

     

CITY STATE ZIP CODE

     

     

     

PHONE E-MAIL

     

     

AFFILIATION WITH NOMINEE

     

RECOMMENDATION #7

NAME TITLE

     

     

COMPANY/ORGANIZATION

     

ADDRESS

     

CITY STATE ZIP CODE

     

     

     

PHONE E-MAIL

     

     

AFFILIATION WITH NOMINEE

     

RECOMMENDATION #8

NAME TITLE

     

     

COMPANY/ORGANIZATION

     

ADDRESS

     

CITY STATE ZIP CODE

     

     

     

PHONE E-MAIL

     

     

AFFILIATION WITH NOMINEE

     

For additional letters of recommendation, please provide the above requested information on a Word document and submit it with this application.

Compliance with Program Terms

I, THE NOMINATOR(S),

     

OF THE FOLLOWING NOMINEE

     

for a National Medal of Technology and Innovation award, by my submission of this nomination do hereby consent to public disclosure of the information contained in this package for the purpose of use or distribution by the Department of Commerce to develop descriptive material, such as magazine articles, Web sites or other means, to increase public awareness of National Medal of Technology and Innovation Laureates and their accomplishments. I do NOT consent to public disclosure of any information deemed personal, as noted below:

     

The Department of Commerce requests that recipients of the National Medal of Technology and Innovation work with its agencies and the National Science and Technology Medals Foundation to share additional information about “lessons learned” regarding U.S. commercial process and competitiveness.

The public reporting burden for the collection of this information is estimated to average 40 hours per response, including the time for reviewing instructions, collecting information, and completing the form. All responses to this request for information are voluntary for purposes of the Paperwork Reduction Act. Please mark clearly any portion of the information submitted that you consider to be proprietary and it will be afforded confidentiality to the extent allowed under the Freedom of Information Act. Notwithstanding any other provision of law, no person is required to respond to, nor shall a person be subject to a penalty for failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB control number. Comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, can be sent to the National Medal of Technology and Innovation, c/o United States Patent and Trademark Office, P.O. Box 1450, Alexandria, VA 22313-1450 (NMTI@uspto.gov).

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Administered by OMB Approval No. 0651-0060

The United States Patent and Trademark Office Expiration Date 4/30/2015

U.S. Department of Commerce

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