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					        AWARD OF INNOVATION 2011 NOMINATION FORM

Deadline for Nomination: February 11, 2011

The Award of Innovation was established by the University of Regina and Innovation
Place to recognize and promote the efforts of researchers involved in
technology/knowledge transfer and/or commercialization.

Award nominees must be faculty, staff or students of the University of Regina, who have
developed an innovative and potentially commercializable technology in their research
program, or have been involved in the successful transfer of that technology/knowledge
to a Canadian company, or to society-at-large, in a way that has had a significant impact
on the well being of Canadians.

A selection committee will choose the best candidate based on
   1) intellectual achievement,
   2) uniqueness and originality,
   3) the stage of development and
   4) degree of commercialization, and
   5) the economic and social benefits, or perceived benefits, to Saskatchewan or
       society in general.

All nominations must be received at the University-Industry Liaison Office by February
11, 2011. Applications will be accepted from candidates who nominate themselves.

Please submit a hard copy of this nomination form to the University-Industry Liaison
Office at the address noted below, along with any supporting materials. The signed
nomination form and accompanying letter should be submitted with the application.

                          University Industry Liaison Office
                                240-2 Research Drive
                                 University of Regina
                                 Regina, SK S4S 7H9
                     Electronic Mail: tamara.wheler@uregina.ca


                          For further information, contact:
                   Amanda Evans, Technology Transfer Coordinator
                        University Industry Liaison Office
                       Email: tamara.wheler@uregina.ca
                           Telephone: (306)585.4986
                                Fax: (306)585.5205




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     AWARD OF INNOVATION 2011 NOMINATION FORM


 1. Individual or Group Information:
 Nominee 1:
    Name: _________________________________________________________________
    Title: __________________________________________________________________
    Organization: ___________________________________________________________
    Address: _______________________________________________________________
    ________________________________________________________________________
    City: ___________________    Province: _____________ Postal Code: __________
    Phone: ____________     Fax: ____________       E-Mail: _____________________


 Nominee 2:
    Name: _________________________________________________________________
    Title: __________________________________________________________________
    Organization: ___________________________________________________________
    Address: _______________________________________________________________
    ________________________________________________________________________
    Phone: ____________     Fax: ____________       E-Mail: _____________________


 Group Nominee:
    Name of Group: ________________________________________________________
    Name of Principal Contact (list all members of Group on reverse): ______________
    Title: __________________________________________________________________
    Organization: ___________________________________________________________
    Address: _______________________________________________________________
    ________________________________________________________________________
    Phone: ____________     Fax: ____________       E-Mail: _____________________



PLEASE USE ADDITIONAL COPIES OF THIS PAGE FOR ADDITIONAL NOMINEES




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    AWARD OF INNOVATION 2011 NOMINATION FORM


2. Executive Summary:

   Please briefly summarize your achievements (or your group’s achievements), and
   explain how these satisfy the criteria of the award, leading to the development
   and/or commercialization of the knowledge/technology. You may submit up to a
   maximum of two pages: include the timeframe; the major challenges or
   constraints; and, the final result. You may submit additional supporting materials
   and information in electronic format, ie on a disk or CD-Rom, with the hard copy
   application (MSWord or PDF files only, please).

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    AWARD OF INNOVATION 2011 NOMINATION FORM

   Executive Summary (cont’d)

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        AWARD OF INNOVATION 2011 NOMINATION FORM


   3. Nominee’s Signature

Name:
                    Surname                 First Name                  Initial
I, the above named nominee, hereby certify that I have read and agree to be bound by the
rules of the award.
Signature:                                                 Date:



Name:
                    Surname                 First Name                  Initial
I, the above named nominee, hereby certify that I have read and agree to be bound by the
rules of the award.
Signature:                                                 Date:

NOTE: Each nominee, if there is more than one, must fill out this form, please use
additional copies of this page for additional nominees.



   4.   Optional endorsement by nominee’s department Head or faculty Dean
   Nomination endorsed by:
Name:                                                                                  _
                    Surname                 First Name                  Initial
Title: __________________________________________________________________

Organization: ____________________________________________________________

Address: ____________________________________________________________________________
          ____________________________________________________________________________

Phone: ________________       Fax: _______________E-Mail:      ____________________


Signature: ________________________________ Date: ________________________




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