Formular

Nominator: _________________________________________________________________

President of the nomination subcommittee: ________________________________________

Nomination form for international jubilee Tesla medals (for year ________ )

Does the nominee accept the nomination? Yes__ No__ Did not check yet__

NAME (individual or institution)__________________________________________________________________

ADDRESS__________________________________________________________________________________

TELEPHONE _______________________________________________________________________________

FAX _____________________________________________________________________________________

EMAIL_____________________________________________________________________________________

HTTP _____________________________________________________________________________________

Text to appear on the certificate to go with the medal

FOR OUTSTANDING CONTRIBUTION TO THE FIELD OF _____________________________________
(major research field of the potential laureate—up to 5 words)

AND ESPECIALLY FOR THE FACT THAT_______________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________
(major contribution for which the nomination has been submitted—up to 30 words)

Justification of the nomination

___________________________________________________________________________________________

Signatures of the nominators

___________________________________________________________________________________________

Additional justification (up to one more page) and/or appendices,
only if absolutely necessary