(please list all members if more than five, a separate list may be attached) – Title First and last name Gender (F/M)* Staff type (A/G)* * Use one of the following, as appropriate: F = Female G = General Staff M = Male A = Academic Staff team nominations (six or more members) Team name Female Male Total Academic Staff General Staff Nominee’s declaration I/We (print name of nominee or team representative) ..……………………………………………………………………………………………………… accept nomination for an Award for Programs that Enhance Learning. Signature Date Head of School / Department / Unit's Support for Nomination and Authorisation I support this nomination on the basis of the attached application. I confirm that the contact details provided are correct and that the nominee/s referred to on this form is/are currently a member/s of this School/Department/Unit's staff. Title Name (print) Position title School/Department/Unit Signature Date
(please list all members – if more than five, a separate list may be attached) Title First and last name Gender (F/M)* Staff type (A/G)* * Use one of the following, as appropriate: F = Female G = General Staff M = Male A = Academic Staff team nominations (six or more members) Team name Female Male Total Academic Staff General Staff Nominee’s declaration I/We (print name of nominee or team representative) ..……………………………………………………………………………………………………… accept nomination for an Award for Programs that Enhance Learning. Signature Date Head of School / Department / Unit's Support for Nomination and Authorisation I support this nomination on the basis of the attached application. I confirm that the contact details provided are correct and that the nominee/s referred to on this form is/are currently a member/s of this School/Department/Unit's staff. Title Name (print) Position title School/Department/Unit Signature Date
2014_EITA_Programs_nomination_form_.docx