The Distinguished Scientific Achievement Award is a prestigious award honoring a scientist who has made a major contribution to liver disease research in basic science or in its application towards the prevention, treatment or cure of liver disease. Nominee Name:_________________________________________ Organization/Institution of Nominee:___________________________________ Mailing Address and Contact Information for Nominee Street: __________________________________________________________________ Street 2: __________________________________________________________________ City: _______________________________ State: _______________________________ Zip: _____________ Telephone: ___________________ Email Address:_________________________________ This nomination is being submitted by (name): __________________________________________ Organization/Institution of Individual Submitting this Nomination:________________________________ Mailing Address and Contact Information for the Individual Submitting this Nomination Street: __________________________________________________________________ Street 2: __________________________________________________________________ City: _______________________________ State: _______________________________ Zip: _____________ Daytime Telephone: ___________________ Email Address:_________________________________ Attachments Required: 1. Letter of recommendation Attach a detailed letter of no more than two pages, on why you think this person should receive the Distinguished Scientific Achievement Award. 2. Nominee’s full Curriculum Vitae Previous recipients of this award can be found at the webpage be below: http:// www.liverfoundation.org/medical-professionals/alf-research-awards-program To submit a nomination, fill out this form and send it along with required documents via email to Megan Glynn at MGlynn@liverfoundation.org For further information, contact Megan Glynn at 646-737-9402 or via email: MGlynn@liverfoundation.org Incomplete nominations and late nominations will not be accepted.