Coeur d’Or™ (Heart of
Gold) Award
Nominations for 2nd Annual Coeur d’Or Awards open August 15, 2007.
Entries close September 15, 2007.
Nomination Form for doctors, individuals, non-governmental
organizations, etc.
Personal Details
Name:
Date of Birth, or Year of Establishment (for organisation):
Address (Residence):
Address (Office):
Phone(s):
Cell phone number:
E-mail:
Professional Details
Qualifications:
Field of Work:
Description (with details of breakthrough tasks achieved, date of
inception, major achievements, how did people benefit from your work, etc.)
(If you are submitting a written nomination form, separate sheets can be
attached for this variable; must not exceed 2 sheets):
Other awards won and/or recognition achieved:
Recommendation/Sponsorship (two):
1. I, (name of sponsor), recommend (name of nominee) for the
prestigious ‘Coeur d’Or’ award. Following is my statement of
support for the nominee, with my e-mail address, and contact details
(statement of support must not exceed 200 words):
2. I, (name of sponsor), recommend (name of nominee) for the
prestigious ‘Coeur d’Or’ award. Following is my statement of
support for the nominee, with my e-mail address, and contact details
(statement of support must not exceed 200 words):
Or
Self Recommendation
(Why should I be considered for the prestigious ‘Coeur d’Or’?
Not more than 200 words)
Place:
Date:
Signature (in Latin characters):
