National Medal of Technology and Innovation Nomination F

U.S. PATENT AND TRADEMARK OFFICE	OMB No. 0651‐0060 | Approved through x/xx/xxxx | FORM PTO‐NMTI-1
Under the Paperwork Reduction Act of 1995, no person is required to respond to a collection of information unless it displays a valid OMB control number

National Medal of Technology and Innovation
Nomination Form 2021

This sample form is for informational purposes only.

You must submit nominations via the online portal.

1. General Information

NOMINATION FOR INDIVIDUAL

Is this individual a U.S. citizen? U.S. citizenship is a requirement.

NAME TITLE

     	     
Pronunciation

COMPANY / NON-PROFIT

     

WORK ADDRESS

     

CITY STATE ZIP CODE

     

     

     

WORK PHONE WORK E-MAIL

     

     

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

     

WORK ADDRESS

     

CITY STATE ZIP CODE

     

     

     

WORK PHONE WORK E-MAIL

     

     

NAME #2 TITLE

     	     
Pronunciation

COMPANY / NON-PROFIT

     

WORK ADDRESS

     

CITY STATE ZIP CODE

     

     

     

WORK PHONE WORK E-MAIL

     

     

NAME #3 TITLE

     	     
Pronunciation

COMPANY / NON-PROFIT

     

WORK ADDRESS

     

CITY STATE ZIP CODE

     

     

     

WORK PHONE WORK E-MAIL

     

     

NAME #4 TITLE

     	     
Pronunciation

COMPANY / NON-PROFIT

     

WORK ADDRESS

     

CITY STATE ZIP CODE

     

     

     

WORK PHONE WORK E-MAIL

     

     

NOMINATION FOR COMPANY/NON-PROFIT (OR DIVISION THEREOF)

Is company/non-profit over 50% owned by U.S. citizens? This is required for consideration.

NAME (Representative) TITLE

     	     
Pronunciation

COMPANY / NON-PROFIT

     
Pronunciation

WORK ADDRESS

     

CITY STATE ZIP CODE

     

     

     

WORK PHONE WORK E-MAIL

     

     

2. 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)

     

PATENTS AND PUBLICATIONS (Limit 1 page/500 words)

     

COPYRIGHTS AND TRADEMARKS (Limit 1 page/500 words)

     

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

     

WORK ADDRESS

     

CITY STATE ZIP CODE

     

     

     

WORK PHONE WORK E-MAIL

     

     

V. Letters of Recommendation

• The nomination may 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 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.

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 the letter writers by midnight ET, DATE.

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

RECOMMENDATION #1

NAME WORK EMAIL

     

     

RECOMMENDATION #2

NAME WORK EMAIL

     

     

RECOMMENDATION #3

NAME WORK EMAIL

     

     

RECOMMENDATION #4

NAME WORK EMAIL

     

     

RECOMMENDATION #5

NAME WORK EMAIL

     

     

RECOMMENDATION #6

NAME WORK EMAIL

     

     

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 Chief Administrative Officer, United States Patent and Trademark Office, P.O. Box 1450, Alexandria, VA 22313-1450 ([email protected]).

Privacy Act Statements

The United States Patent and Trademark Office (USPTO) collects this information under authority of 15 USC 3711. The information in this system of records is used to manage records such as name, postal address, telephone number, e-mail address, citizenship, employment history, and other information pertaining to an individual’s activities, statements containing various kind of information with respect to the contributions of the individual(s) and/or group(s). The information you provide is protected from disclosure to third parties in accordance with the Privacy Act.

However, routine uses of this information may include disclosure to the following: to law enforcement and investigation in the event that the system of records indicates a violation or potential violation of law; to a Federal, state, local, or international agency, in response to its request; to an agency, organization, or individual for the purpose of performing audit or oversight operations as authorized by law; to non-federal personnel under contract to the agency; to a court for adjudication and litigation; to the Department of Justice for Freedom of Information Act (FOIA) assistance; to members of congress working on behalf of an individual; to the Office of Personnel Management (OPM) for personnel research purposes; to National Archives and Records Administration for inspection of records. Failure to provide any part of the requested information may result in an inability to process nominations. The applicable Privacy Act System of Records Notice for this information is COMMERCE/PAT-TM-21 National Medal of Technology and Innovation Nominations: Federal Register / Vol. 73, No. 18 / Monday, January 28, 2008 / Notices 4851 available at https://www.uspto.gov/sites/default/files/sorn/uspto-pasorn-21.pdf.

Administered by OMB Approval No. 0651-0060

The United States Patent and Trademark Office Expiration Date 6/30/2021

U.S. Department of Commerce

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