2006 Victoria Prize Nomination Form

							                  2006 Victoria Prize Nomination Form

        This must be completed and submitted with all nominations for the 2006 Victoria Prize.


PROPONENT’S DETAILS
 1     I nominate                                                         for the 2006 Victoria Prize.
                                       Name of Nominee
 2     Name of Proponent
 3     Position within Organisation
       (if applicable)
 4     Name of Organisation
       (if applicable)
 5     Address (home or work – please specify)




        BH Tel.                                    Mob.
        Email


                           Signature of proponent(s)                                      Date


NOMINEE’S DETAILS
(please attach details of all nominees, if more than one individual is being nominated)
  6    Name of Nominee
 7     Position within
       Organisation (if applicable)
 8     Name of Organisation
       (if applicable)
 9     Address and contact details (home or work – please specify)




        BH Tel.                                    Mob.
        Email

 10     The nominee must sign the statement below verifying the accuracy of the information
        provided.
      I have read the attached nomination for the 2006 Victoria Prize as well as the nomination
      guide, and confirm that the information in the nomination is true and accurate.
      Furthermore, as the nominee, I permit the release of all materials submitted on my
      behalf for the purposes of the selection process and understand that in the event of
      being awarded the Victoria Prize a description of the work being acclaimed and images
      of myself will be publicised.


                             Signature of nominee(s)                                      Date


         Important: Please complete next page
REFEREES
      Please provide details of at least three referees qualified to assess the nomination. One
      of these referees must be the head of the nominee’s organisation or department. Please
      ensure that each referee has been provided with a copy of the nomination by the 10 April
      2006 closing date.
11    After the closing date, the Department will contact the nominated referees to request
      referee reports.

     Referee (Head of Organisation or Department)
     Full Name

     Email

     Position

     Organisation
      Address



                    Country                                          Postcode

     Tel. (business hours)                                         Fax



     Referee
     Full Name

     Email

     Position

     Organisation
      Address



                    Country                                          Postcode

     Tel. (business hours)                                         Fax



     Referee
     Full Name

     Email

     Position

     Organisation
      Address



                    Country                                          Postcode

     Tel. (business hours)                                         Fax



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Please fill out the following survey and submit with your application, before 5.00pm on
10 April 2006.


How did you find out about the Victoria Prize?
Please help us to promote the Victoria Prize in an effective way by completing this quick
survey. Your assistance is greatly appreciated.



Please indicate how you heard out about the 2006 Victoria Prize. Indicate more than
one response, as appropriate.

Print article or advertisement:        The Age
                                       The Herald Sun
                                       Other (please specify)


Internet:                              www.business.vic.gov.au
                                       Other (please specify)


Past recipient:                        Yes


Flier:                                 Yes


Letter/flier in the mail:              Yes


Newsletter or e-bulletin:              University postgraduate association
                                       University Alumni association
                                       University research grants office
                                       Professional association
                                       Other (please specify)


From professional colleagues:          Yes
How did your professional
colleague hear of the award?           Please specify

Other (please specify):




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Checklist

Have you:

1. Completed all points required for the nomination as outlined on page 4.

2. Submitted:

      A signed original of the nomination;
      Six copies of the nomination;
      Evidence to support Australian citizenship/residency and Victorian residency
       requirements; and

3. Provided nominated referees with a copy of the nomination by the 10 April 2006 closing
   date.

4. Completed the survey.




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