The ‘Panos Englezos Prize’ Nomination Form Nominee Information Name: ______________________________________________________________________ Title: ________________________________________________________________________ Mailing Address: ______________________________________________________________ Telephone Number: ____________________________________________________________ Fax Number: _________________________________________________________________ e-mail: ______________________________________________________________________
Description of the specific contribution of the nominee for which he/she is nominated for the award.
Nominator Information Name: ______________________________________________________________________ Title: ________________________________________________________________________ Mailing Address: ______________________________________________________________ Telephone Number: ____________________________________________________________ Fax Number: _________________________________________________________________ e-mail: ______________________________________________________________________
PLEASE ENCLOSE: 1. Completed Nomination Form 2. Nomination Letter of Support 3. Nominee CV
Signature:
Date: mm/dd/yyyy