iYGEC6 Nomination Form

Nominee information (up to 2 persons)

Surname First name
Date of birth Country
Affiliation
Department Business title
Mailing address
Telephone Email

Surname First name

Date of birth Country
Affiliation
Department Business title
Mailing address
Telephone Email

Nominator information
Surname First name
Name of society
Business title
Mailing address
Telephone Email

Nominator ___________ _____________ Date___________________________