Principal’s Medal Application Form 2010

1. PROPOSER

If this is a self nomination please leave this section blank.

Name:			
E-mail Address:		
Contact Number:		

2.  NOMINEE 

Student		Staff		Group (no more than 4 members)		

If this is a group application please give additional nominee details on an attached sheet. 

2.1	Nominee Details

Title:		First Name:		Surname:		
Street Address:		
City/Town:		Postcode:		
Daytime Telephone:		Email:		

Please complete the relevant section 2.2 or 2.3

2.2	Staff Only
Job Title:		

2.3 Student Only	
Course:		

3. COMMUNITY INVOLVEMENT DETAILS

Please provide on no more than one A4 piece of paper a description of the nominee’s community involvement and details of any information which you wish to provide to support this nomination.

4.  SUPPORTING STATEMENTS

Please provide contact details for an additional individual who can supply a supporting statement to verify the nominee’s achievements.

Name:			
E-mail Address:		
Contact Number:		

5. SUBMIT APPLICATION

Please return your completed form to the address below:

Development and Alumni
The University of Edinburgh
Charles Stewart House
9 – 16 Chambers Street
Edinburgh EH1 1HT

Deadline 
The 2010 deadline has been extended and is now Friday 5 November 2010.

Further Assistance Required
If you need any further information or assistance please contact Sanne Dijkstra-Downie on 0131 650 2236 or sanne.dijkstra-downie@ed.ac.uk.