Young Extension Worker Award
(Nomination due by October 31)

ASABE: The Society for Engineering in Agricultural, Food and Biological System

NOMINATION FORM

PRIVILEGED INFORMATION

Please limit nomination information to 2 printed pages.
Do Not use Cut and Paste, please type in the information.
This form, along with the 3-5 support letters, will provide the only information used for the evaluation of your candidate.
The form must be complete.

1 Candidate's Name :
first name middle initial last name
Member Number:

2Primary Employment Position:
Institution/Company:
telephone number (include area code):

address:

3 Date of Birth (month, date, year):
Place of Birth, city: state: country:

4 Citizen of (name of country ):
if naturalized give date (month, date, year):

5 Education, list all degrees earned, dates, fields, institutions :
6 Registered Engineer (list states):

7 Area of Specialization:

8 Specific Outstanding Technical and Professional Engineering Accomplishments and Contributions Meriting Selection of the Award Include information on the impact of the nominee’s program. (Please limit to 500 words) Attach 3-5 letters of support describing the impact of the nominee’s extension program from individuals in a position to evaluate the technical and professional engineering accomplishments and contributions. These letters are to come from the 3-5 references listed at the bottom of the form.

9 Record of Professional Work Experience (list principal positions and describe primary responsibilities for each;
include dates):

10 Contributions of Record (list complete citations, including all authors, for five (5) publications of most significant input).
Summary:

    Refereed journal articles
Patents
  Books
Book chapters
Conf. proceedings
Other publications
Other contributions of record

11 Principal Technical Society Membership (including grades) and Activities, and Other Noteworthy Pertinent Accomplishments in Engineering and Public Service (boards, committees, consultant-ships, important offices held and contributions to society):


12 Professional Recognition (honors, awards, prizes, honorary degrees; give specifics):

13 Proposed Citation (not more than 20 carefully edited words that reflect specific documented contributions):

Nominated by:
Name:
Affiliation:
Telephone (include area code):
E-Mail Address:

References- List of 3-5 reference names. Each reference must submit a letter of support.
1. Name:
Affiliation:
2. Name:
Affiliation:
3. Name:
Affiliation:
4. Name:
Affiliation:
5. Name:
Affiliation: