Green Neuroscience Prize nomination Form

Full name of nominator ^* (required)

Email address of nominator ^* (required)

Nominator's workplace / affiliation (University, NHS Trust, company, institute etc) ^* (required)

To make a nomination you must be a member of the BNA. Please confirm that you are a member. ^* (required)

Yes, I am a BNA Member

Who are you nominating? ^* (required)

I am nominating myself.

I am nominating someone else.

Name of nominee ^* (required)

Nominee's workplace / affiliation (University, NHS Trust, company, institute etc) ^* (required)

Please select the career role which best describes the nominee's position: ^* (required)

Undergraduate student (including preclinical medical students)

Postgraduate student (Masters, PhD, F1/F2 or MD-PhD)

Early career (within 5 years of highest degree / completing F2)

Established researcher / clinical scientist

Research support staff (lab manager, technician etc)

N/A (Team)

other

Is the nominee aware that you are putting them forward for this prize? ^* (required)

Yes

No

Please complete the below if you are nominating yourself for the Student researcher prize, Individual researcher prize, or you are nominating your team for the Team prize and you are the designated point of contact/team leader. Please select the career role which best describes your position:

Undergraduate student (including preclinical medical students)

Postgraduate student (Masters, PhD, F1/F2 or MD-PhD)

Early career (within 5 years of highest degree / completing F2)

Established researcher / clinical scientist

Research support staff (lab manager, technician etc)

Other

Self-nominations need to be supported by a letter of recommendation. Please confirm that you will ensure this is sent to [email protected]. Self-nominations without letters of support cannot be considered.

I confirm I will submit a letter of support.

Why should this person be considered for the award? Please make a case for why the nominee should be recognised for their work in neuroscience. (Maximum 4000 characters including spaces, alternatively please send this information to the BNA office as a word document supporting your application) ^* (required)

Please mention anything else of which you feel the selection committee should be aware when making their decision.

Please confirm that you're aware of the following: o That you have read the eligibility criteria for the BNA Green Neuroscience Prize and you/your nominee meet them accordingly. o That you consent to the collection and recording of data for purposes of administering BNA Prizes and to evaluate it. Details of all nominators and nominees will be retained by the BNA for a period of 8 years; after this period the data will be anonymised and retained indefinitely. o That the BNA may publicise prize winners and their work for which they are being recognised (through interviews, website posts, social media, newsletters etc.) ^* (required)

Yes, I have read and accept these conditions