Section 1. Nominee Details - please provide details of the person being nominated

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* 1. Title

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* 2. Full name

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* 3. Date of Birth

Date

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* 4. Job Title

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* 5. Organisation

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* 6. Please detail the MRC funding that the nominee has received to date

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* 7. Email address

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* 8. Mobile / home phone number

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* 9. Gender identity

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* 11. Does the nominee consider themself to have a disability?

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* 12. Please declare any circumstances that should be taken into consideration that may have influenced career progression of the nominee, for example: disability/illness, career breaks, caring and childcare responsibilities, etc.

Section 2. Nominator Details - please provide details of the person making the nomination

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* 13. Title

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* 14. Full Name

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* 15. Job Title

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* 16. Organisation

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* 17. Email address

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* 18. Mobile/home phone number

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* 19. Relationship to the nominee

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* 20. How did you hear about the MRC Millennium Medal?

Section 3. Nomination Form Upload
Please download a nomination form and upload the completed copy below including endorsement from a member of the senior leadership team at the institution. The deadline for applications is Friday 10th September 2021 at 17:00. If you experience any issues when submitting your entry, or have any questions about the background, eligibility and process of awarding, please visit www.mrc.ukri.org/successes/awards-recognition or contact the team by emailing medal@mrc.ukri.org

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* 21. Please upload the completed nomination form here.

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