Nomination Form 2012 Jacobs Prize

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