KUWAIT PRIZE NOMINATION FORMDeclaration and Affidavit

I Click here to enter text. Declare and Acknowledge of the originality of my nominated scientific research outcomes and take the full responsibilities in case of breaching this commitment.

(A) Background Data :

(1) Field of Award Choose an item.

(2) Name of Nominee Click here to enter text.

(3) Year and Place of Birth : Click here to enter text.

(4) Present Nationality : Click here to enter text. Past Nationality: Click here to enter text.

(5) Proof of Arab Origin : ☐ Valid Passport

☐ Birth Certificate in an Arabic country

(6) Address : Click here to enter text.

(7) E-mail Address : Click here to enter text.

(8) Telephone Numbers : 1- Work Click here to enter text.

2- Fax: Click here to enter text.3- Mobile: Click here to enter text.4- Home: Click here to enter text.

Note: KFAS requires that winners of Kuwait Prize present proof of their Arabic origin either an Arabic birth certificate or a valid Arabic passport to visit Kuwait and attend the Prize ceremony.

(1)

(9) Qualifications (Bachelor-Master-PhD):

FieldYearInstitutionDegree

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(2)

(10) Academic Honors, Grants and Awards (Prize Name -Grantor- Year)

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(3)

(11) Academic and Administrative experience starting with current position :

Job Title Organization/Company Name From To

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(4)

(B) Scientific Production: Journal Publications and books Published during the past 20 years

Section (1) Publications in refereed journals (For papers that are accepted for publications and have not

been published yet, please attach the acceptance letter).

Please list the publications with the name of the author(s), title, journal, and year of publication. When attaching the publications number them so that they match the list.

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(B) Scientific Production: Section (2)

Books: Please list the book with the name of authors, editors, translators, the title, the year of publication, and the publisher. When attaching the books number them so that they match the list.

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(B) This section is for candidates who are self-nominating for the prize. Kindly provide a list of five references: Four academics/researchers and one academic institution that would support your self-nomination.

Name of the Academic/Researchers and Institution

Address and Email

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(7)