ASPIRE 2018 Nomination Form 
INSTRUCTIONS: Thank you for your interest in being selected to represent Australia in the 2018 ASPIRE Prize. Please send all required documents below and submit to the Grants and Awards Officer at the Australian Academy of Science – grants@science.org.au

REQUIRED DOCUMENTS: 
1)	Nomination form; 
2)	Nominee’s  Curriculum Vitae; 
3)	One letter of recommendation for consideration; 
4)	A photo of nominee (image must be larger than 250*300 pixels) 

INDIVIDUAL SUBMISSIONS DUE: 5pm (AEDT) Monday 11 April 2018  

SECTION 1 OF 5 - Nomination Statement (up to 300 words): Please describe how the nominee has demonstrated excellence in scientific research in the field of “Smart Technologies for Healthy Societies” and cooperation with scientists from other APEC member economies.	

	
SECTION 2 OF 5 - Nominee Information	
Member Economy:	
Last Name:	First Name:	
Date of Birth (day/month/year):	
Address:	
	
Telephone:	Email:	
Title:	
Institution/Affiliation:	
Field of Research:	
SECTION 3 OF 5 - List of Peer Reviewed Scholarly Publications: Please list the nominee’s peer reviewed publications (publication titles should be translated into English). The nominee’s record of scholarly publication will be evaluated on its merits, and nominees are encouraged to include publications regardless of the publisher. Please continue onto separate page if necessary.	

Please denote which scholarly publications include co-authors from APEC member economies, for example:
1.	A.S. Barnard, H. Konishi, H. Xu, ‘Morphology mapping of platinum catalysts over the entire nanoscale’, Catal. Sci. & Tech. (2011) accepted [APEC Authors]
2.	H. Guo, A.S. Barnard, ‘Computational challenges in accurate modeling of iron oxides and oxyhydroxides, and the prediction of environmentally sensitive phase transformations’, Phys. Rev. B, 83 (2011) 094112
3. L.Y. Chang, E. Osawa, A.S. Barnard, ‘Confirmation of the electrostatic self-assembly of nanodiamonds’, Nanoscale, 3 (2011) 958 [APEC Authors]

	
SECTION 4 OF 5 - Other Awards/Achievements/Contributions to market-led innovations: Please list below in English; please continue onto separate page if necessary. 	
Please denote which, if applicable, have a connection to other APEC member economies. 

	
SECTION 5 OF 5 – Local Nominator Information (If Nomination Form is submitted by nominee himself or herself, do not fill out this section)	
Last Name:	First Name:	
Telephone:	Email:	
Relation to Nominee (if any):	
Title:	
Institution/Affiliation:	
Nominator Signature (typed):	

Remember to include the following attachments along with this Nomination Form:

•	Nominee’s Curriculum Vitae
•	One letter of recommendation
•	Photo of nominee (image must be larger than 250*300 pixels):