PTO-NMTI-1 National Medal of Technology and Innovation Nomination F

OMB Control Number: 0651-0080 Expiration
Date: XX/XX/XXXX

PTO-NMTI-1

NATIONAL MEDAL OF TECHNOLOGY AND INNOVATION
SAMPLE 2023 Nomination Form

This sample form is for informational purposes only.
You must submit nominations via the online portal by 11:59 PM ET on May 26, 2023.

I.

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

WORK PHONE

WORK E-MAIL

NAME #2

ZIP CODE

TITLE

Pronunciation

COMPANY / NON-PROFIT
WORK ADDRESS
CITY

STATE

ZIP CODE

Administered by
The United States Patent and Trademark Office

OMB Approval No. 0651-0060
Expiration Date 5/31/2024

U.S. Department of Commerce

Page 1 of 6

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

Administered by
The United States Patent and Trademark Office

OMB Approval No. 0651-0060
Expiration Date 5/31/2024

U.S. Department of Commerce

Page 2 of 6

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)
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

Administered by
The United States Patent and Trademark Office

OMB Approval No. 0651-0060
Expiration Date 5/31/2024

U.S. Department of Commerce

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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).

•

A minimum of one and a maximum of 6 letters of recommendation are required. 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
11:59 p.m. ET, May 26, 2023.

Please complete contact information for letters of recommendation or support below.
RECOMMENDATION #1
NAME

WORK EMAIL

RECOMMENDATION #2
NAME

WORK EMAIL

RECOMMENDATION #3
Administered by
The United States Patent and Trademark Office

OMB Approval No. 0651-0060
Expiration Date 5/31/2024

U.S. Department of Commerce

Page 4 of 6

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.
A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be
subject to a penalty for failure to comply with an information collection subject to the requirements of the
Paperwork Reduction Act of 1995, unless the information collection has a valid OMB Control Number. The
OMB Control Number for this information collection is 0651-0060. Public burden for this application is
estimated to average 40 hours per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the information
collection. Send comments regarding this burden estimate or any other aspect of this information collection,
including suggestions for reducing this burden to the Office of the Chief Administrative Officer, United States
Patent and Trademark Office, P.O. Box 1450, Alexandria, VA 22313-1450 or email
[email protected]. ([email protected]).

Administered by
The United States Patent and Trademark Office

OMB Approval No. 0651-0060
Expiration Date 5/31/2024

U.S. Department of Commerce

Page 5 of 6

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
The United States Patent and Trademark Office

OMB Approval No. 0651-0060
Expiration Date 5/31/2024

U.S. Department of Commerce

Page 6 of 6