National Medal of Technology and Innovation 2019 Nomination Form

NATIONAL MEDAL OF TECHNOLOGY AND INNOVATION
2019 Nomination Form
(Nominations must be submitted by midnight ET April 5, 2019)
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 / NON-PROFIT
ADDRESS
CITY

STATE

PHONE

E-MAIL

ZIP CODE

NOMINATION FOR TEAM (Up to four Individuals)
Are all members of this team U.S. citizens? (U.S. citizenship is a requirement.)
NAME #1
TITLE
Pronunciation

COMPANY / NON-PROFIT
ADDRESS
CITY

STATE

PHONE

E-MAIL

NAME #2

ZIP CODE

TITLE

Pronunciation

COMPANY / NON-PROFIT
ADDRESS
CITY

STATE

ZIP CODE

Administered by
The United States Patent and Trademark Office

OMB Approval No. 0651-0060
Expiration Date 6/30/2021

U.S. Department of Commerce

Page 1 of 7

PHONE

E-MAIL

NAME #3

TITLE

Pronunciation

COMPANY / NON-PROFIT
ADDRESS
CITY

STATE

PHONE

E-MAIL

NAME #4

ZIP CODE

TITLE

Pronunciation

COMPANY / NON-PROFIT
ADDRESS
CITY

STATE

PHONE

E-MAIL

ZIP CODE

NOMINATION FOR COMPANY/NON-PROFIT (OR DIVISION THEREOF)
Is company/non-profit over 50% owned by U.S. citizens?
NAME (Representative)
TITLE

Yes

No

Pronunciation

COMPANY / NON-PROFIT
Pronunciation

ADDRESS
CITY

STATE

PHONE

E-MAIL

ZIP CODE

Administered by
The United States Patent and Trademark Office

OMB Approval No. 0651-0060
Expiration Date 6/30/2021

U.S. Department of Commerce

Page 2 of 7

PAST MEDAL RECIPIENT(S) WITHIN THE COMPANY/NON-PROFIT
NAME(S)
AWARD YEAR CONTRIBUTION/ACHIEVEMENT

II. Summary of Nominee’s Contribution/Achievement
Refer to the Nomination Guidelines at www.uspto.gov/nmti.
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)

COMPREHENSIVE DESCRIPTION OF CONTRIBUTION/ACHIEVEMENT (Limit 5 pages/2,500 words)
Please see the Evaluation Criteria in the Nomination Guidelines at www.uspto.gov/nmti.

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

Administered by
The United States Patent and Trademark Office

OMB Approval No. 0651-0060
Expiration Date 6/30/2021

U.S. Department of Commerce

Page 3 of 7

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

FOR TEAMS: EXPLAIN THE RELATIONSHIP AMONG TEAM MEMBERS
Please describe why these individuals are being nominated as a team.

FOR COMPANIES/NON-PROFITS: PLEASE PROVIDE INSTITUTIONAL HISTORY

IV. Nominator Information
NOMINATOR’S RELATIONSHIP TO NOMINEE AND CONTRIBUTION
NOMINATOR’S NAME

TITLE

COMPANY/NON-PROFIT
ADDRESS
CITY

STATE

PHONE

E-MAIL

ZIP CODE

V. Letters of Recommendation
•

The nomination must include a maximum of six letters of recommendation or support from individuals who have
first-hand knowledge of the cited achievement(s). The letters should be from a diverse group of individuals or
organziations (ie. the letters should not all come from the nominee’s workplace).

•

Successful nominations typically have 3-6 quality letters of recommendation from different experts that directly
address the impact of the nominee’s achievement on their field, other fields, their community, nationally, and/or
globally.

•

Letters should be saved as a Microsoft Word document 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_Jane_recSmith

•

Contact information for those sending letters of recommendation should be included in the nomination form in the
section below.

•

Letters of recommendation must be uploaded to the nomination portal by midnight ET, April 5, 2019.

Administered by
The United States Patent and Trademark Office

OMB Approval No. 0651-0060
Expiration Date 6/30/2021

U.S. Department of Commerce

Page 4 of 7

Please complete contact information for letters of recommendation or support below.

RECOMMENDATION #1
NAME

TITLE

COMPANY/NON-PROFIT
ADDRESS
CITY

STATE

PHONE

E-MAIL

ZIP CODE

AFFILIATION WITH NOMINEE

RECOMMENDATION #2
NAME

TITLE

COMPANY/NON-PROFIT
ADDRESS
CITY

STATE

PHONE

E-MAIL

ZIP CODE

AFFILIATION WITH NOMINEE

RECOMMENDATION #3
NAME

TITLE

COMPANY/NON-PROFIT
ADDRESS
CITY

STATE

PHONE

E-MAIL

ZIP CODE

AFFILIATION WITH NOMINEE

Administered by
The United States Patent and Trademark Office

OMB Approval No. 0651-0060
Expiration Date 6/30/2021

U.S. Department of Commerce

Page 5 of 7

RECOMMENDATION #4
NAME

TITLE

COMPANY/NON-PROFIT
ADDRESS
CITY

STATE

PHONE

E-MAIL

ZIP CODE

AFFILIATION WITH NOMINEE

RECOMMENDATION #5
NAME

TITLE

COMPANY/NON-PROFIT
ADDRESS
CITY

STATE

PHONE

E-MAIL

ZIP CODE

AFFILIATION WITH NOMINEE

RECOMMENDATION #6
NAME

TITLE

COMPANY/NON-PROFIT
ADDRESS
CITY

STATE

PHONE

E-MAIL

ZIP CODE

AFFILIATION WITH NOMINEE

Administered by
The United States Patent and Trademark Office

OMB Approval No. 0651-0060
Expiration Date 6/30/2021

U.S. Department of Commerce

Page 6 of 7

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
Expiration Date 6/30/2021

U.S. Department of Commerce

Page 7 of 7