<p> CIC Fellowship Nomination Form</p><p>Name of Nominee:</p><p>Present Position:</p><p>Employer:</p><p>Address:</p><p>E-mail:</p><p>Nominated by:</p><p>Address:</p><p>E-mail:</p><p>If the nomination is being submitted on behalf of a Local Section or Division please provide the name of the group:</p><p>SPONSORS</p><p>List the names of three sponsors whose statements will be submitted before October 1. At least one sponsor should be from outside the candidate's organization and need not be a member of the CIC.</p><p>1. </p><p>2.</p><p>3. I. PERSONAL INFORMATION</p><p>Postsecondary Education</p><p>Course/Program Institution Dates Degree/Diploma</p><p>Employment History</p><p>Dates Position/Employer</p><p>Additional pages may be inserted if the space provided is insufficient. II. SCIENTIFIC, ENGINEERING AND TECHNICAL CONTRIBUTIONS</p><p>Description of Major Contributions</p><p>Describe the significance of the scientific, engineering and technical contributions of the nominee (approx. 250 words).</p><p>Documentation</p><p>Please indicate the total number of each of the following:</p><p>(1) Refereed papers in journals:</p><p>(2) Papers in refereed conference proceedings:</p><p>(3) Non-refereed papers, including book reviews: </p><p>(4) Reports: </p><p>(5) Books and Manuals: </p><p>(6) Patents: </p><p>(7) Other: </p><p>Please include a list of the 10 most significant papers or reports over the last six years: Give details of restricted reports and patents: III. CIC, CSC, CSChE and CSCT ACTIVITIES</p><p>Member of the CIC (MCIC) since </p><p>The Nominee should normally be a member of the CIC for a minimum of 10 years.</p><p>Description of the candidate’s influence on objectives of the CIC & its Constituent Societies</p><p>Documentation of Activity (1) CIC Activity:</p><p>(2) CSC, CSChE and CSCT Activity:</p><p>(3) Local Section Activity:</p><p>(4) Division Activity:</p><p>(5) Other Activity: IV. MANAGEMENT OF SCIENCE, ENGINEERING OR TECHNOLOGY Give an example of Managerial and Supervisory Responsibilities.</p><p>Documentation List Managerial positions, other Professional Activities and Contributions to Policies and Decision-Making. V. TEACHING, MENTORING AND PUBLIC AWARENESS Description Describe the effectiveness of the candidate in these areas.</p><p>Documentation List contributions to Teaching, Mentoring and Public Awareness. VI. SPECIAL ACHIEVEMENTS Describe the candidate's most outstanding achievements and their significance.</p><p>Provide a brief citation of one or two sentences for publication in Canadian Chemical News (ACCN) as part of the announcement of the election of new Fellows.</p><p>The CIC and Societies would like to acknowledge outstanding work carried out in the chemical community to superiors as well as to the general public. In the event that your candidate is chosen for this award, please provide the following information:</p><p>Canadidate’s supervisor:</p><p>NAME:</p><p>ADDRESS:</p><p>E-MAIL: VII. OTHER OPTIONAL MATERIAL A résumé (limit 9 pages) is encouraged. This may provide additional information, not necessarily included in the nomination.</p><p>VIII. MEDIA CONTACTS</p><p>Please provide a fax or e-mail address if possible:</p><p>Submit nominations electronically to [email protected]</p>