2017 Goldman Environmental Prize Nomination Form

Please submit your nomination by email to Katie at Katie@goldmanprize.org before the

submission deadline: Monday, May 2, 2016 at 5:00pm Pacific time. Please note that
nominations should be a minimum of five (5) pages and a maximum of ten (10), not
including supporting material. Please do not alter or edit the format of the nomination form.
Prior to submitting your nomination, please contact Katie with the name(s) of the individual(s)
you intend to nominate. We do not accept nominations or provide honoraria for nominees who
are currently active (nominated in the past two years). Please feel free to contact Katie if you
have any other questions about your nomination(s). Contact us if you would rather mail or fax
your nomination.
Identification of Nominee
First Name:
Surname (Family Name):
Address:
Country:
Gender:
Email:
Home phone:
Work phone:
Skype:
Website:
Identification of Organizational Nominator
Name of organization:
Name of primary contact at organization:
Relationship to nominee:
Address:
Phone:
Skype:
Email:
Researcher(s)
Required if the nomination was researched and/or written by someone other than the nominator
listed above.
Name:
Name of organization, if applicable:
Relationship to nominee:
Address:
Phone:
Skype:

Email:
Nomination Essays
1. Short summary of environmental achievement (one paragraph)
Summarize the achievement for which the nominee is being recognized.

For the narrative portion of the nomination, focus on the current accomplishment (within the
last two years). You must use the following subheadings:
2. Detailed description of recent environmental achievement
a. The background of the problem or issue
b. How the nominee used grassroots strategies to bring about their environmental achievement
(list dates)
c. Results of nominee's work (list dates of achievement)
d.

Why this accomplishment is significant on a national and/or international level

3. Detailed description of the nominees circumstances

e. Describe the environment (social, political, economic) in which the nominee works
f. Controversy or concerns surrounding the nominee's work or circumstances
g. Threats and/or personal risks faced by the nominee (please be specific)
h. Has the nominee experienced any hardships (such as being detained, imprisoned, sued,
deported or arrested) for his or her work? If yes, please be specific
i. How has the nominee gone above and beyond any job responsibilities to accomplish their
achievement?
j. How would an increase in media attention support or be detrimental or dangerous for the
individual, should he/she win the Prize?

k. Are there any reasons why this person should not receive the Prize?

Additional Information about the Nominee

Please fill out to the best of your knowledge.

Date of birth or approximate age:

Nationality:

Where was the nominee born and raised?

Languages spoken:

Is the nominee married or does he/she live with a domestic partner?

Does the nominee have children?

Current occupation or job title:

If applicable, awards and recognition received by the nominee, including the year(s) the
award(s) were given and include the organization or government body giving the award:

If applicable, school/university attended and degree(s) earned. Include year(s):

References
List two personal references and three professional references that are well acquainted with the
nominee and his/her work. We do not accept nominations that omit references.
Personal References:
1. Name & Title & Organization:
Relationship to nominee:
Phone(s):
Skype:
Email(s):
Address:
2. Name & Title & Organization:
Relationship to nominee:
Phone(s):
Skype:
Email(s):

Address:
Professional References:
1. Name & Title & Organization:
Relationship to nominee:
Phone(s):
Skype:
Email(s):
Address:
2. Name & Title & Organization:
Relationship to nominee:
Phone(s):
Skype:
Email(s):
Address:
3. Name & Title & Organization:
Relationship to nominee:
Phone(s):
Skype:
Email(s):
Address:
Sources
List your main sources of information for the facts and data contained in this nomination. Be
specific and list the persons interviewed, websites, articles, print media sources, etc.
Supporting Material
If available, include web links to newspaper and magazine articles that document the nominee's
environmental activities. These materials are most useful if they were recently published, come
from a reputable news source, and mention the nominees name (English preferred but not
required).