NOMINATION FORM

2015 Scientific Innovators of Influence List
Proudly sponsored by:
The Australian Academy of Technological Sciences & Engineering,
together with the Australian Science & Innovation Forum.
See www.ASIForum.net for more information.

Patron and envoy, Former Deputy Prime Minister, Mr Tim Fischer AC.
Start the nomination
 
Eligibility


Before starting, let's complete the eligibility checklist. 

If you answer "No" to any of the questions, the application is not eligible.
 
Nominee is currently engaged in an innovative activity. *

This list WILL recognise emerging innovators. 
The aim is NOT to recognise career achievements.
     
 
The innovative activity has a financial, social or environmental impact? *

The nominee must have done more than publish a paper or get a patent.
For instance, they have launched or substantially improved a product, service or process.
     
 
The innovative activity has a major science, technology, engineering or mathematics component. *

     
 
Nominee is an Australian resident or citizen *

Australian citizens residing overseas ARE eligible.
Foreign citizens residing in Australia  at the time of nomination OR innovation ARE eligible
     
 
Nominee is an individual or a team *

Companies are NOT eligible.
You may nominate an individual or  team WITHIN a company.
     
 
The nominee has done more than contribute money. *

People involved in investment and finance play a critical role in the development of science and technology innovations and businesses.

Nomination of investors and mentors is welcomed, however, nominees must have done something over and above contribute money. For instance, the provision of mentoring, teaching, sponsorship or advice.
     
 
Nominator is over 18 years of age *

That means you!
     
 
OK, if you answered YES to all of the above, you are ready to proceed with the nomination.  Here we go.....

 
Nominator's Contact Details (That's you)

Please insert the details of the person making the nomination. We may contact you if we need to clarify the nomination.  You can nominate yourself. You can nominate multiple people.
 
Your Phone Number *

Please include country code and exclude spaces e.g.  61398640900.
 
Your Title *

Your preferred title (e.g. Dr, Prof, Ms, Mr):
 
Your First Name *

 
Your Family Name *

 
Country of Residence *

 
Organisation *

Your primary work organisation. If retired or not working, please leave blank.
 
Your Organisation's Website

 
Are You Nominating Yourself? *

If self-nominating, you can skip the next section (Nominee's Contact Details).
     
 
Nominee's Contact Details

If you are nominating yourself, you can skip to the next section.

If you are nominating a team, just put the details of the team leader. Team members can be added at the end.

 
Nominee's Phone Number

Please include country code and exclude spaces e.g.  61398640900.
 
Nominee's Title

Nominee's preferred title (e.g. Dr, Prof, Ms, Mr):
 
Nominee's First Name

 
Nominee's Family Name

 
Nominee's Country of Residence

 
Organisation

Nominee's primary work organisation.
 
Website of Nominee

 
Nominee's Characteristics

 
Gender of Nominee or Team Spokesperson: *



 
Career Stage of Nominee *

For researchers, early-mid career might be up to 15 years following completion of a PhD.
For business people, early-mid career might be under 50 years of age.


 
Type of Nominee *

Innovator: implements a new scientific or technical product, service, process or policy.
Entrepreneur: starts or scales (grows) a  science or technology  business.
Investor: supports the financial aspects of business development in science or technology.

 
Nominee's Work Environment *


 
The Nomination

 
What is the Product, Service or Process? *

Identify the innovative product,  service or process.
It must have been launched within the past three years by the nominee.
 
Why is this Innovative *

Provide a description of the innovation in less than 300 words.
 
Financial Impact *

Rate the innovation based on its financial impact e.g. revenue, profit, sales, market capitalization, efficiencies, cost savings or return on investment. 

Higher score indicates a more positive financial impact.





 
Social Impact *

Rate the innovation on its social impact eg education, communications, reduction in poverty, improvement in health or creative output.

Higher score indicates greater impact for the better.





 
Environmental Impact *

Rate the innovation based on the environmental impact. 

Higher score indicates greater impact for the better.





 
Optional: Evidence supporting the impact.

If available, please provide any information supporting the impact of the innovaiton.
 
Optional: For Teams Only

Additional details if the nominee is a team. 
Otherwise, skip to the end to submit.
 
Team Member 2: Title

Team member's preferred title (e.g. Dr, Prof, Ms, Mr):
 
Team Member 2: First Name

 
Team Member 2: Family Name

 
Add Extra Team Members, if Required

Use title, first name last name.
 
Thank you for completing the nomination.

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