ICCBBA One World Award Nomination Form

Please complete all five sections before submitting.

Section 1: Nominee Information
Section 2: Nominator Information
Section 3: Nominee Achievements
Section 4: References
Section 5: Attachments

Is the Candidate	Self-Nominated Nominated by a Second Person
*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 92374 USA through November 2012

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