Your Information
Title	Dr. Mr. Ms.
First Name
Middle Initial
Last Name
Company
Business Title
Division
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Phone (w/area code)
Fax (w/area code)
Email
Web site
Nominee Information
Name of Nominee
Affiliation of Nominee
Please submit a short essay in the field to the right explaining why you wish to nominate your candidate for the van der Ziel Award.
For a record of your registration, print out this completed form after submitting it.