Shoman Foundation: Nomination Form

Application for Nomination to the Award

First: Information about the Nominee

First Name *:

Middle Name *:

Grandfather *:

Last Name *:

Place and Date of Birth *:

Nationality *:

Place of Permanent Residence :

Current Employer :

Academic Rank *:

Professor Associate Professor
Assistant Professor Teacher Other

Employment Address

University/Scientific Institution : *

College : *

Department : *

Phone No. :

Fax No. :

E-mail :

Home Info. :

Home Address :

Phone No. :

Fax No. :

Address while on vacation :

Nominee’s specific specialization : *

Academic qualifications *:

Degree	Date	University	Subject/Thesis
Bachelor’s Degree
Master’s
PhD

Award for which nominee is competing *:

Summary of submitted work :

Work	Number of Contributions
Published research
Research submitted to conferences, for a and specialized workshops
Patents
Books published
Books reviewed

Summary of Services to the Community and Educational Institutions :

Prizes and Awards Won by Nominee, and Dates of Their Presentations :

Second: Information about Nominating Parties

First Nominating Professor :

Name *:

Address :

Phone No. :

Fax No. :

E-mail :

Second nominating professor :

Name *:

Address :

Phone No. :

Fax No. :

E-mail :

Reasons for Nomination *:

To be attached with the nomination:

Three copies of the nominee’s scientific work
Official documents indicating birthday (birth certificate or passport)
Personal biography
List of published or completed works
Any other documents in support of nomination

Notes:

Kindly, fill out the required information completely so as to simplify the task of the Committee.
Nominees from outside Jordan are kindly requested to attach a recent photocopy of their passports.

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