MCCC Green Award 2012

NOMINATION FORM
1. Category [Please tick () ONE only] Reducing Greenhouse Gas Emissions/Improving Air Quality Minimizing Waste Protecting land/water resources and biodiversity Green Entrepreneur/Manager

Promoting green concept or environmental sustainability in the media

Community action for the environment: volunteers and members of non-profit organization

2. Title

Details of Nominee

Name Age Designation Organization Address

City State Country Tel No

Zip Code

Mobile No Fax No

Email
MCCC GREEN AWARD 2012

Website/ Homepage Academic/ Professional Qualifications Honours and Awards (List only Professional Honours and Awards which are conferred. Do not list Membership of Professional Society which is obtained by application)

3. Title Name

Details of Nominator

Designation Organization

Address

City State Country Tel No Email Website/ Homepage

Zip Code

Mobile No Fax No

MCCC GREEN AWARD 2012

4.

Nominators relationship to candidate

MCCC GREEN AWARD 2012

(The nominator should mention how long he/she has personally known the nominee and how well he/ she are acquainted with the activities and contribution of the nominee, professional or otherwise ;).

(Please use attachment if space provided is insufficient)

5.

Describe your nominee's actions/products/services/activities/research contribution?

(Please use attachment if space provided is insufficient)

6.

(Please use attachment if space provided is insufficient) 7 Describe what motivated your nominee to make a difference in his/her actions/ products/services/activities/ research contribution?

(Please use attachment if space provided is insufficient)

MCCC GREEN AWARD 2012

Describe the achievement and impact of your nominee's actions/products/services/ activities/research contribution that have had on Environmental Sustainability and Green Growth in the ASEAN region?

8.

Please describe the innovative and/or creative aspects of the nomination.

MCCC GREEN AWARD 2012

(Please use attachment if space provided is insufficient) 9. Why do you think that this nominee should be awarded the Green Soldier Award?

(Please use attachment if space provided is insufficient)

REFEREE Title Name Designation Organization

Address

City State Country Tel No Email Relationship with Nominee

Zip Code

Mobile No Fax No

MCCC GREEN AWARD 2012

10. Details of Referee (Referee cannot be from the same institution as the nominee. Please provide details of a referee whom we can approach for a reference. Please ensure referees contact details are valid.)

Declaration I, the undersigned grants to the ASEAN Academy of Engineering and Technology the right to copy, reprint, quote or publish the above information as part of its awards program or other public communication. Nomination materials become the property of ASEAN Academy of Engineering and Technology and will not be returned.

_________________________________ (Signature) Nominator: Official Stamp: Date:

MCCC GREEN AWARD 2012