This form is to be submitted to UNESCO (Division for Science Policy and Capacity-Building, Natural Science Sector, UNESCO, 7 place de Fontenoy, 75007 Paris, France) by 27 May 2017 solely by the National Commission for UNESCO in the candidate's home country.
1. Name of the Member State submitting the candidature:
2. Name of the Body proposing the candidature (if appropriate):
3. Name, address, telephone and fax number, email of candidate:
4. Nationality of candidate:
5. List enclosed annexes (books, CD-ROMs, cassettes, videocassettes, news paper articles, etc):
6. List translations/summaries of annexes in English and/or French (if original in another language):
7. Description of the candidate's career in science popularization (use as many sheets as necessary):