Global Health Council - Gates Award for Global Health Nomination Form

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2011 Gates Award for Global Health - Online Nomination Form

All Nominations Must be Submitted in English

(All fields with an * are required)

Click here for: 2011 Nomination Background & Criteria | Past Winners

*Nominated Organization:

Name and Title of Director:

*Salutation:

Mr. Ms. Mrs. Dr.

*Given/First Name:

Middle Initial:

*Family/Last Name:

*Title:

*Address:

*City:

*State/Province:

*Postal Code:

*Country:

*Telephone:

*Fax:

*E-mail Address:

*Website Address:
(if none, type "none")

Nominator:

*Salutation:

Mr. Ms. Mrs. Dr.

*Given/First Name:

Middle Initial:

*Family/Last Name:

*Title:

*Organization:

*Address:

*City:

*State/Province:

*Postal Code:

*Country:

*Telephone:

*Fax:

*E-mail Address:

*Website Address:
(if none, type "none")

*Relationship of Nominator to Nominated Organization:

*Has your nominee received any prior recognition? Please describe.

*Have any quantitative evaluations been conducted to support the stated results of the nominee's programs? Please describe.

*Year the Organization Started Its Business:

* Please provide two individuals who can serve as additional references.

Reference 1

* First Name:	* Last Name:
* Title:
* Organization:
* Address:
* City:	* State/Province:
* Country:	* Postal Code:
* Telephone:	Fax: (format as: xxx-xxx-xxxx)
* E-mail Address:

Reference 2

* First Name:	* Last Name:
* Title:
* Organization:
* Address:
* City:	* State/Province:
* Country:	* Postal Code:
* Telephone:	Fax: (format as: xxx-xxx-xxxx)
* E-mail Address:

* How did you hear of the Award?
(please check one)
Global Health Council website

Global Health Council print publication

Other publication (please specify)

Other (please specify)

*Attach Your Nomination Letter Here:

Nomination letter is required; your submission will not be considered if you do not submit a nomination letter.

Please limit your letter to no more than five (5) typewritten pages. The letter should highlight the nomination criteria above.

(Use "Browse" button to retrieve your "nomination letter" file from your desktop. This document should be in ".doc" or ".txt" format)

Your nomination must be received no later than Friday, Oct. 29, 2010.

Please submit your nomination online by clicking on "Submit Nomination" button below.

Questions? Please contact Dawn Carey, Awards Program Coordinator, at dcarey@globalhealth.org or 802.649.1340 ext. 2144 with questions.

38th Annual International Conference on Global Health