2006 Fresh Innovators nomination form

You may nominate as an individual or, preferably, be nominated by a relevant organisation

Please email or fax your nominations to Niall Byrne at niall@freshinnovators.org or fax (03) 9923 6008 by Tuesday 18 April 2006. An emailed MS Word file is the easiest for us to process.

Essential additional material can be posted to: Science in Public, PO Box 199, Drysdale, Victoria 3222.

If you have questions please call or email Tim Thwaites on 03 9383 4600 / tim@freshinnovators.org; Niall Byrne on 03 5253 1391 / niall@freshinnovators.org; Sarah Brooker on 0413 332 489 / sarah@freshinnovators.org

Download nomination form here: as a Word Document or PDF.
(If you want to save the file locally on your computer then right click on 'Word' or 'PDF' and select 'save target as'. Alternatively, you can use the HTML version below.)

Name and contact details

Nominee’s name:
Nominee’s position:
Nominee’s organisation:
Nominee’s relevant qualifications: (where and when obtained)
Address:
Date of birth:
Work phone:
Fax:
E-mail:
After hours contact:
Web site:
Nominator’s name:
Nominator’s position:
Nominator’s organisation:
Nominator’s address:
Nominator’s phone no:
Nominator’s fax no:
Nominator’s e-mail:

Project details of innovation

Project /innovation title:

Your preferred newspaper headline: 8 words or less

Project summary in everyday English

Inspire us – persuade us that we should read the rest of the form – but don’t use more than 60 words.

This section is critical to the success of your nomination.

Project description in everyday English:

who, what, when, where, how, why in less than 400 words.

This section is critical to the success of your application.

This and the project summary will be used in assessing if you can present your research to the public and the media using plain language.

Unnecessary jargon will kill your chances.

Supplementary information

Evidence of utility

Eg referees/attached references demonstrating the utility of your innovation. If it’s a scientific development, is there peer review or other evidence of its utility?

If it’s a gadget has it been trialled, is there a market for it, is it already being sold, has it been patented?

Graphical material

What props, photographic, graphical or audio-visual material do you have to facilitate the presentation and reporting of your innovation?

What publicity has this work received to date?

eg press clippings, articles, radio/TV interviews

We are looking for stories that the media will regard as new.

Be honest – some minor media coverage will not jeopardise your nomination.

Collaborators/business partners

Please list any collaborators/business partners who should be acknowledged in the presentation of this innovation.

(Name, affiliation, contact details – phone and email)

Background

Please list any attached background information eg. abstracts of relevant papers, information sheets, graphics etc.

Referees

Please provide names, positions, phone, fax and email details for three referees

Sign off

I, (Name in blocks)________________________________________________________,

submit this nomination for ‘Fresh Innovators’.

I am available to attend and take part in the Fresh Innovators program from Monday 8 to Wednesday 10 May 2006 in Brisbane, and to speak to the public and the media.

I am happy to give presentations if required after I return home from the Fresh Innovators program.

The information on this form is accurate and I have all the approvals I need from my organisation and my commercial partners to talk to the media about my innovation.

I acknowledge that it is my responsibility to ensure that I have appropriate intellectual property protection.

Signed: Date:

(If you are emailing the form don’t worry about a signature – we will trust you – and get your sign-off if you are selected.)

Organisers of similar events sometimes ask Fresh Innovators to provide names of scientists interested in public communication of science.

Do you give permission for your work contact details to be passed on to third parties? Yes/No
(delete as appropriate - your answer here will not affect your nomination).

For more information, please contact:

Sarah Brooker on sarah@freshinnovators.org ph 0413 332 489
or Niall Byrne niall@freshinnovators.org ph (03) 5253 1391

2006 Fresh Innovators nomination form

Name and contact details

Nominee’s name:

Nominee’s position:

Nominee’s organisation:

Nominee’s relevant qualifications: (where and when obtained)

Address:

Date of birth:

Work phone:

Fax:

E-mail:

After hours contact:

Web site:

Nominator’s name:

Nominator’s position:

Nominator’s organisation:

Nominator’s address:

Nominator’s phone no:

Nominator’s fax no:

Nominator’s e-mail: