FUNDAÇÃO CALOUSTE GULBENKIAN

APPLICATION FORM

CALOUSTE GULBENKIAN INTERNATIONAL PRIZE

I. NOMINATOR IDENTIFICATION

Name *:

Organisation:

Title:

Address *:

Postal Code *: Country *:

Telephone: Fax: Mobile:

E-mail: Webpage:

II. NOMINEE IDENTIFICATION (INDIVIDUALS OR ORGANISATIONS)

Individual:

Address *:

Postal Code *: Country *:

Telephone: Fax: Mobile:

E-mail: Webpage:

Organisation:

Type of organisation *: Official Registration Number:

Legal representative *: Title *:

Statutory aims:

Composition of Board of Directors:

*
Fields marked with * are compulsory.

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 Brief description of the organisation *:

Address *:

Postal Code *: Country *:

Telephone: Fax: Mobile:

E-mail: Webpage:

III. NOMINEE AND PRIZE CRITERIA

Connection between the nominator and the nominee (when applicable):

Description of the impact, originality and innovative character of the nominee’s contribution to the Prize areas
(Maximum 6500 characters) *:

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 FUNDAÇÃO CALOUSTE GULBENKIAN

Description of the impact, originality and innovative character of the nominee’s contribution to the Prize areas
(continuation) *:

Additional Information or enclosed documents:

NOMINATOR DECLARATION

TO THE BEST OF MY KNOWLEDGE, ALL THE INFORMATION CONTAINED IN THIS APPLICATION FORM IS
CORRECT AND RELIABLE. I READ THE NORMS OF THE PRIZE TO WHICH I NOMINATE THE NOMINEE.

Validate

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