Eurasian Pharma Awards – Application Form

"*" indicates required fields

Applicant’s Details

The person proposing the nominee for the award

Applicant's Full Name*

Name, Patronymic Name Surname

Company Name*

Job Title*

Work Phone Number*

Mobile Phone Number*

Email*

Nominee Company Details

Company’s Head*

Name, Patronymic Name Surname

Company’s Head Job Title*

Company Name*

Company Website Address*

Company Information*

(max 150 words)

Company Logo

Accepted file types: jpg, jpeg, png, gif, pdf, eps, ai, Max. file size: 8 MB.

Application for Nominations

Any company can be offered for participation in up to 3 nominations

Participation in*

One Nomination

Two Nominations

Three Nominations

Please Select the Nomination*

Nominee’s Name and Surname*

Name, Patronymic Name Surname

Job Title*

Work Phone Number*

Mobile Phone Number*

Email*

Details*

Please provide information about nominated company representatives and the best projects that can help to confirm achieved results. Maximum 300 words.

Please Select the Second Nomination*

Nominee’s Name and Surname*

Name, Patronymic Name Surname

Job Title*

Work Phone Number*

Mobile Phone Number*

Email*

Details*

Please provide information about nominated company representatives and the best projects that can help to confirm achieved results. Maximum 300 words.

Please Select the Third Nomination*

Nominee’s Name and Surname*

Name, Patronymic Name Surname

Job Title*

Work Phone Number*

Mobile Phone Number*

Email*

Details*

Please provide information about nominated company representatives and the best projects that can help to confirm achieved results. Maximum 300 words.

Company Representative

Contact details of the company representative responsible for liaising with the organiser

Company Representative's Name and Surname*

Name, Patronymic Name Surname

Job Title*

Email*

Work Phone Number*

Mobile Phone Number*