ICCBBA One World Award Nomination Form

Please complete all five sections before submitting.

Is the Candidate



*Name
*Title:
*Employer
*Street Address:
*City:
*State/Province:
*Country:
*Postal Code:
*Telephone Number:
*Email Address

Name of person nominating
Street Address:
City:
State/Province:
Country:
Postal Code:
Telephone Number:
Email Address:
If someone other than the nominee is completing this form, please complete this section:

Summary of candidate's achievements in the fields of transfusion or transplant medicine (500 words or less)


*Name
Reference 1
*Address:

*Email Address:
Name
Reference 2 (if applicable)
Address:

Email Address:
If someone other than the nominee is completing this form, only one of referee is required.

Resume of nominee
Copies of relevant publications
Copies of relevant publications
Copies of relevant publications
Copies of relevant publications
Statement of referee 1
Statement of referee 2
Please submit the following items. You may attach digital versions to this form, or send via postal mail to the ICCBBA office, Attn: Paul Ashford, PO Box 11309, San Bernardino, California 92423 USA Nominations will be accepted through 30 April 2013.

Verify Your Humanity

You can download a PDF copy for the nomination form here.

Nomination forms can be sent via Email. You can also fax this form to ICCBBA at +1 (909) 793-6214 or send via postal mail to the ICCBBA office, Attn: Paul Ashford, PO Box 11309, San Bernardino, California 92423 USA 

Nominations are accepted until 30 April 2013