Excellence in Teaching Awards: Application Form

Please complete the form and click the Submit button at the bottom of the page. Once you submitted the form, you will receive a confirmation e-mail at the e-mail address you give on the form.

(*) Indicates required fields

	Personal details
	Name and title*
	Work address*
	Work tel*
	E-mail*
	Position*
	Date of appointment*	(mm/yy)
	Previous employment*
	Date of birth*	(dd/mm/yyyy)
	Nationality*
	Qualifications
	Undergraduate*
	Institution*
	Class of degree*
	Date awarded*	(dd/mm/yyyy)
	Postgraduate*
	Institution*
	Date awarded*	(dd/mm/yyyy)
	Membership of engineering institutions
	Achievements
	What have been your most notable teaching achievements to date?*
	What have been your most notable personal achievements to date?*
	What in your opinion distinguishes you from your peer group and worthy of an award?*
	Career Plans
	What are your plans in the short term (up to 3 years)?*
	Future Plans
	If your university were to be awarded the prize, what initiative(s) would the money be allocated to?*
	Please note that all winners will be requested to update ExxonMobil on their progress from time to time, and to provide information on how their award has been put to good use
	Head of Department*
	Referee one*
	Referee two*
	Signed*
	Date*	(dd/mm/yyyy)
	Before you can submit your request, we need to make sure it is not an automated computer program that's submitting the form. To achieve this, please enter the two words displayed below in the textbox, separated by a space.

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Schemes for university lecturers ExxonMobil Excellence in Teaching Awards Past ExxonMobil teaching fellows Past ExxonMobil Excellence in Teaching Awardees Industrial secondments