The HAGUE AWARD NOMINATION FORM

The HAGUE AWARD NOMINATION FORM

Please type or use block letters.

Please submit the completed form by 15 September 2017 to: Office of Strategy and Policy, OPCW, Johan de Wittlaan 32, 2517 JR The Hague, the Netherlands;

e-mail:

Part I: Applicant / Nominee information

Title
First name
Last name
Date of birth / establishment (in case of organisation) / Day / Month / Year
Nationality
Gender / Male / Female
Permanent Address
Profession
Contact Details of the applicant/nominee

Three referees who can independently ascertain the applicant/nominee’s outstanding contribution to the core objectives of the Organisation

Referee No 1 Name
Referee No 1 E-mail address
Referee No 1 Phone Number
Referee No 2 Name
Referee No 2 E-mail address
Referee No 2 Phone Number
Referee No 3 Name
Referee No 3 E-mail address
Referee No 3 Phone Number

Part II: Nominator information (if applicable)

Title
Family name
First name
Last name
Nationality
Profession
Contact details
Relationship to the candidate
Reason for nomination

Part III: Statement in Support of application / nomination

Provide a narrative (between 500 and 1,000 words) that persuasively demonstrates why theindividual/organisation is a worthy candidate for The OPCW-The Hague Award. Provide details on:

1.  the contribution (publication, innovation, etc) submitted for recognition by The Award;

2.  the impact on promoting the core objectives of the Organisation and the Convention’s implementation;

3.  any recognition by another entity for the same contribution;

4.  any relationship or previous engagement withthe OPCW;

5.  any financial sponsorship in support of the contribution;

6.  any applicable patents or copyright restrictions;

7.  any foreseeable constraints regarding the reception of the award on part of the applicant / nominee;

8.  any collaborators, in case of a contribution based on a joint effort, and;

9.  any future plans concerning the use and/or further development of the contribution.