2014 Goldman Environmental Prize Nomination Form

Please submit your nomination by email to Niloofar Ganjian, at efore the submission deadline: Friday, April 12, 2013

Prior to submitting your nomination, please contact Ms. Ganjianwith the name(s) of the individual(s) you intend to nominate.We do not accept nominations or provide honoraria for nominees who are currently active (nominated in the past two years). Please feel free to contact Ms. Ganjian if you have any other questions about your nomination(s). Contact us if you would rather mail or fax your nomination.

Identification of Nominee

First Name:

Surname (Family Name):

Address:

Email:

Home phone:

Work phone:

Skype:

Website:

Identification of Organizational Nominator

Name of organization:

Name of primary contact at organization:

Address:

Phone:

Skype:

Email:

Researcher(s)

Required if the nomination was researched and/or written by someone other than the nominator listed above.

Name:

Name of organization, if applicable

Address:

Phone:

Skype:

Email:

Nomination Essays

1. Short summary of environmental achievement (one paragraph)

Summarize the achievement for which the nominee is being recognized.

2. Detailed description of recent environmental achievement (approx. three to five pages)

Describe the outstanding environmental achievement of the nominee, with a focus on the current accomplishment. You must use the following subheadings:

  1. The background of the problem or issue
  1. How the nominee used grassroots strategies to bring about their environmental achievement (list dates)
  1. Results of nominee's work (list dates of achievement)
  1. Why this accomplishment is significant on a national and/or international level
  1. Controversy or concerns surrounding the nominee's work or circumstances
  1. Threats and/or personal risks faced by the nominee (please be specific)
  1. Has the nominee experienced any hardships, such as being detained, imprisoned, sued, deported or arrested for his or her work? If yes, please explain.
  1. Could an increase in media attention be detrimental or dangerous for the individual, should he/she win the Prize? If so, please explain.

Additional Information about the Nominee

Please fill out to the best of your knowledge.

Date of birth or approximate age:

Nationality:

Where was the nominee born and raised?

Languages spoken:

Is the nominee married or does he/she live with a domestic partner?

Does the nominee have children?

Current occupation or job title:

If applicable, awards and recognition received by the nominee, including the year(s) the award(s) were given and include the organization or government body giving the award:

If applicable, school/university attended and degree(s) earned. Include year(s):

References

Listtwo personal references and three professional references that are well acquainted with the nominee and his/her work.We do not accept nominations that omit references.

Personal References:

  1. Name & Title & Organization:

Relationship to nominee:

Phone(s):

Skype:

Email(s):

Address:

  1. Name & Title & Organization:

Relationship to nominee:

Phone(s):

Skype:

Email(s):

Address:

Professional References:

  1. Name & Title & Organization:

Relationship to nominee:

Phone(s):

Skype:

Email(s):

Address:

  1. Name & Title & Organization:

Relationship to nominee:

Phone(s):

Skype:

Email(s):

Address:

  1. Name & Title & Organization:

Relationship to nominee:

Phone(s):

Skype:

Email(s):

Address:

Sources

List your main sources of information for the facts and data contained in this nomination. Be specific and list the persons interviewed, websites, articles, print media sources, etc.

Supporting Material

If available, include web links to newspaper and magazine articles (no more than five) that document the nominee's environmental activities. These materials are most useful if they were recently published, come from a reputable news source, and mention the nominee’s name (English preferred but not required). Attach a list of all of the supporting materials being submitted. Also attach a separate list of books and videos about the candidate’s work which we may request at a later date. Do not send books or videos unless requested.