APEN Open Award for Excellence in Extension Nomination Form

Please provide details of the Nominee for the APEN Open Award for Excellence in Extension.
(If you are nominating a person without their knowledge, there will be extra contact details for you to complete at the bottom of the form.)

Title

First Name

Last Name

Email Address

Mobile Number:

Address

City

State

Postcode

Country

Organisation

Date of Birth

Remember to put the year of birth as the calendar function will want to put this year.

Job Title

Description of the work program completed within the last five years.

Provide a summary outlining the work done (up to 200 words) 1500

Please briefly address the selection criteria listed below

• The applicability of the work in the broader practice of extension and contribution to the extension practice profession through providing training, mentoring, papers, article and/or manuals

1000

• Leadership in a major extension program/initiative

1000

• The use or development of extension principles in the work

1000

• Evidence of the effectiveness and efficiency of the work

200

• A commitment to ongoing professional development

500

• APEN membership and/or participation in APEN events would be highly regarded

200

Final Comments (100 words)

1500

Referee 1

Please provide the name, email address and mobile number of an independent referee able to comment upon the work

Referee 2

Please provide the name, email address and mobile number of a second independent referee able to comment upon the work

Nominator Contact details

If different to the Nominee, please provide your name, email address and mobile number.

Evidence of the work may be sent by email to: info@apen.org.au

Email address