Step 1 of 3: Intent to Nominate

The Intent-to-Nominate form is the first step in preparing and submitting the Nomination Package. The information on this form will be automatically associated with each document in your package and will enable us to better assist you throughout the nomination process.

Once you have submitted your Intent-to-Nominate form, you will receive your Access Code. You will then be able to use your Access Code at any time to come back and complete or update the rest of the Nomination Package.

Important Dates:

The Intent-to-Nominate form can be submitted up to the close of nominations at 5:00 pm (PST) on Wednesday, May 31, 2017. For a chance to win the VIP Package of four tickets to the 2017 Dr. Rogers Prize Award Gala, submit this form prior to April 15th 5:00 PM (PST).

Note: All form fields are required except where noted as optional.

Intent To Nominate:

I am pleased to provide notice of my intention to complete and submit a Nomination Package for the Dr. Rogers Prize in the name of the following Nominee:

Nominee Information
Nominee First Name:
Nominee Last Name:
Company/Institution:
Title:
Country:
Street Address:

This address will be used for all post/courier correspondence regarding the Dr. Rogers Prize.
City:
Province/State:
Postal/ZIP Code:
Home Phone:
Office Phone:
Cell Phone:
(optional)
Email Address:
Confirm Email:
Please type the email address twice in the spaces above to confirm.
Website/Blog:
(optional)
Nominator Information
Nominator First Name:
Nominator Last Name:
Company/Institution:
Title:
Country:
Street Address:

This address will be used for all post/courier correspondence regarding the Dr. Rogers Prize.
City:
Province/State:
Postal/ZIP Code:
Home Phone:
Office Phone:
Cell Phone:
(optional)
Email Address:
Confirm Email:
Please type the email address twice in the spaces above to confirm.
Website/Blog:
(optional)

Upon submitting this form, you and your Nominee will both receive an email containing a unique Access Code specific to your nomination. Keep this code as it is required to gain access to your Nomination Package.

At all times throughout this process you have support available to you. Should you have questions, require assistance completing the forms, or wish to receive the forms in a different format, please contact the Dr. Rogers Prize Coordinator.

Please wait while your submission is processed.