National Medal of Technology and Innovation 2012 Nomination Form

NATIONAL MEDAL OF TECHNOLOGY AND INNOVATION
2012 Nomination Form
(Nominations must be submitted by 5:00 p.m. ET March 31, 2012 to [email protected])
INSTRUCTIONS: To enter information onto the form, click inside the blank box and begin typing.

I.

General Information

NOMINATION FOR INDIVIDUAL
Is this individual a U.S. citizen? (U.S. Citizenship is a requirement.)
NAME
TITLE

Yes

No

Yes

No

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.)
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

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Expiration Date 7/31/2012

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?
NAME (Representative)
TITLE

Yes

No

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

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II. 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)

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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

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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

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V.

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 [email protected], 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
Richard Maulsby, Program Manager, at (571) 272-8333. Letters of recommendation must arrive by 5:00 p.m.
ET, March 31, 2012.

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

PHONE

E-MAIL

ZIP CODE

AFFILIATION WITH NOMINEE

RECOMMENDATION #2
NAME

TITLE

COMPANY/ORGANIZATION
ADDRESS
CITY

STATE

PHONE

E-MAIL

ZIP CODE

AFFILIATION WITH NOMINEE

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RECOMMENDATION #3
NAME

TITLE

COMPANY/ORGANIZATION
ADDRESS
CITY

STATE

PHONE

E-MAIL

ZIP CODE

AFFILIATION WITH NOMINEE

RECOMMENDATION #4
NAME

TITLE

COMPANY/ORGANIZATION
ADDRESS
CITY

STATE

PHONE

E-MAIL

ZIP CODE

AFFILIATION WITH NOMINEE

RECOMMENDATION #5
NAME

TITLE

COMPANY/ORGANIZATION
ADDRESS
CITY

STATE

PHONE

E-MAIL

ZIP CODE

AFFILIATION WITH NOMINEE

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OMB Approval No. 0651-0060

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Expiration Date 7/31/2012

RECOMMENDATION #6
NAME

TITLE

COMPANY/ORGANIZATION
ADDRESS
CITY

STATE

PHONE

E-MAIL

ZIP CODE

AFFILIATION WITH NOMINEE

RECOMMENDATION #7
NAME

TITLE

COMPANY/ORGANIZATION
ADDRESS
CITY

STATE

PHONE

E-MAIL

ZIP CODE

AFFILIATION WITH NOMINEE

RECOMMENDATION #8
NAME

TITLE

COMPANY/ORGANIZATION
ADDRESS
CITY

STATE

PHONE

E-MAIL

ZIP CODE

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

Administered by
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OMB Approval No. 0651-0060

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Expiration Date 7/31/2012

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 ([email protected]).

Administered by
The United States Patent and Trademark Office

OMB Approval No. 0651-0060

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Expiration Date 7/31/2012