BECKMAN COULTER C RES AWARD

Transcription

1 ORGANISATION ENDEAVOR: How many years has the nominee been working on this endeavor? Please list the region, country/countries served by this work? Please estimate the number of people impacted by the work in? Does the nominee s organisation/endeavor have any key partnerships or affiliations that it has leveraged as a key to its success? Yes No IF YES please provide a list Optional: If you think it would be helpful for our understanding of the impact of the organisation/ endeavor of your nominee you are welcome to provide us with 1-2 articles to support this work and/or 1-2 video links. Please continue on a separate sheet if required. All fields are required. Please type or print clearly. Note: Nominators should attach their own signed letter of nomination to this form along with the CV resume of the nominee. Page 1 of 11

2 NOMINEE: Name: Position/ Organisation: Address: City: State: Post code: Country: Citizenship: Phone (work): Phone (other): Organisation/ endeavors website: Page 2 of 11

3 NOMINEE: Describe the mission of your nominee s organisation / endeavor in one paragraph: Is this the first time the nominee has been nominated? If no please list the year(s) of previous nominations: Yes No Is the nominee the sole founder of the organisation / endeavor? If no please list any co-founder (s) and their role(s) past and current: Yes No Please list any other significant awards, prizes and recognitions the nominee has received, including dates (You may use an additional sheet if required) May we have permission to share the nominee s work within our network? Yes No Page 3 of 11

4 FOUR KEY QUESTIONS: 1) What is your nominee s vision for change to improve outcomes fighting HIV/AIDS in their community? Please state the nominee name in the upper right corner of any additional sheets. Please continue on a separate sheet if required. Page 4 of 11

5 FOUR KEY QUESTIONS: 2) How has your nominee impacted their community and lives of PLHIV by enacting his/her vision and what have been the measurable results? Please state the nominee name in the upper right corner of any additional sheets. Please continue on a separate sheet if required. Page 5 of 11

6 FOUR KEY QUESTIONS: 3) How has and does your nominee exhibit dedication, commitment and impact in their community fighting HIV/AIDS? Please state the nominee name in the upper right corner of any additional sheets. Please continue on a separate sheet if required. Page 6 of 11

7 FOUR KEY QUESTIONS: 4) How do your nominee s values and universal regard for humanity inspire others? Describe how your nominee has inspired others. Please state the nominee name in the upper right corner of any additional sheets. Please continue on a separate sheet if required. Page 7 of 11

8 NOMINATOR: (Who fills in these forms and writes the letter of nomination): Name: Position/ Organisation: Address: City: State: Post code: Country: Citizenship: Phone (work): Phone (other): Disclaimer All nominators grant Beckman Coulter Life Sciences the right to copy, reprint, quote or publish the information submitted as part of its awards program or other public communication. Nomination materials become the property of Beckman Coulter Life Sciences and will not be returned. Page 8 of 11

9 Submission: Please ensure all fields have been completed and all information is legible. Please ensure any additional sheets or supporting information clearly states the nominee s name in the upper right hand corner. Yes No I have included a signed letter of nomination with the nominee name clearly stated. I have included a CV/Resume of the nominee (if available) I have submitted additional sheets of information with the nominee name clearly stated How to Deliver Your Nomination Package: All materials must be submitted in one including original letters and forms signed by their respective authors, without exception. All nominations must be received in the office no later than. 5pm GMT; April 14th Nominations move forward for consideration together as soon as the nomination process closes. In fairness to the cohort of nominees, late nominations will neither be considered nor acknowledged. The submission address All nominations will be acknowledged in writing, by to all members of the nominating team, with a copy to the nominee. Nominee Name (Print) Signature Date Nomitaror Name (Print) Signature Date Nominator materials become the property of The Beckman Coulter and will not be returned. Nominators grant to The Beckman Coulter the right to copy, reprint, and quote or publish from nomination materials as part of its awards program or other public communication. Page 9 of 11

10 ADDITIONAL NOTES: Page 10 of 11

11 RULES & ELIGIBILITY: The The Cares ( ) will consist of a $5000 donation, made in the name of the recipient of the, to a charitable organization chosen by the recipient of the from a pre-defined list. The is designed to recognize individuals who have shown care, dedication and commitment in their communities as part of the fight against HIV/AIDS. Nominees should represent humanitarian values reflective of sustainable work over a period of time and will be individuals who are considered within their communities as people who have made a difference helping people. A: Eligibility for nomination 1. Nominees must be individuals who are citizens of and resident in all sub Saharan African country that is not subjected to embargo by the United States government. 2. Nominees may be employees of a charitable organization, laboratory, hospital or civic organization. They may also be individuals who represent a personal mission and whose work is voluntary. 3. Individuals may not nominate themselves for the ; self-nominations will be discarded. 4. Individuals who have previously won an will be ineligible for future s. 5. By submitting a nomination, the person who does so represents that he/she has obtained the consent of the nominee to participate in the scheme. 6. Officers, employees, agents and contractors of Beckman Coulter and its affiliated and subsidiary companies, including all Danaher operating companies, as well as their family members, are ineligible both to be nominated and to make nominations. 7. Members of the Independent Advisory Committee are ineligible both to be nominated and to make nominations. 8. Each individual may nominate only one nominee. B: Nomination process 1. Nominees may be selected by anyone who is eligible to make a nomination, by using the form provided on com. 2. The nomination period will run from 1st December, 2016 until April 14th, ( Closing Date ). Nominations received after the Closing Date will not be considered. C: Selection of recipient 1. recipients will be selected by an independent advisory committee consisting of Maurine M. Murtagh; Francois Venter; Ana Teasdale; Francesca Celletti; Lesley Scott ( Committee ). 2. The Committee will, by simple majority vote, select the recipient of the from among a shortlist of 3 nominee s after review of all nominations received by the Closing Date. 3. In selecting the recipient of the, the Committee will consider, in particular, the way in which the recipient represents the values outlined in section A of these Rules. 4. Selection from among the nominees will not be influenced by race, gender, age, sexual orientation, political or religious affiliation, place of employment, purchase of products or services from Beckman Coulter or its affiliated companies, or any other reason unconnected with the values outlined in section A of these Rules. 5. The number of nominations received for a single nominee will not affect the Committee s decision. 6. The Committee will, in selecting the Recipient of the, follow these Rules. D: Conditions of participation; right to withdraw 1. All nominees will be notified in writing of their nomination for the no later than April 14th. 2. Nominees will have the right to withdraw from the selection process at any time 3. Any nominee whose written acceptance of these Rules is not received by April 14th, will be deemed to have withdrawn from the selection process. 4. Acceptance of a nomination indicates that the nominee accepts Beckman Coulter s right to publicly name the nominee as the recipient or as a runner-up, including but not limited to issuing a press release and publishing a related dossier on the Beckman Coulter Website. 5. If a nominee is chosen as the recipient, he or she will be required to attend an award ceremony. E: Announcement of recipient 1. The 3 shortlisted nominees, including the eventual recipient of the, will be notified privately no later than November 9th, and will be publicly announced at the International Conference on AIDS and STIs in Africa (ICASA) will be held in Abidjan, Cote D Ivoire, 4th - 9th December, 2. Nominees who have not been shortlisted will not receive any notification. F: Miscellaneous 1. The is non-exchangeable and non-transferable and is not redeemable for other prizes. 2. Beckman Coulter reserves the right to cancel the at any time before announcing the recipient of the. 3. The Committee s decision as to the recipient of the is final and no correspondence will be entered into. 4. Personal details submitted in connection with the will be treated with the utmost confidence by Beckman Coulter. For further details please refer to our privacy policy at FLOW Page 11 of 11