Burton Award Nomination Form

Please complete the form in its entirety and submit your entry by February 17, 2012. The information designated by an asterisk * is required for proper submission of nominations.

NOMINATING PARTY INFORMATION

Name:*
Title/Position:
Firm/Organization:*
Office Address:*
City:*
State:*
Zip:*
Telephone:*
Email address:*

CANDIDATE INFORMATION (ThE Individual or group BeING NOMINATED)

Name:*
Title/Position:
Firm/Organization:
Office Address:
City:
State:
Zip:
Telephone:
Email address:

SuPPlEMENTAl INFORMATION

Please describe the candidate’s innovative idea(s) on regulatory reform (250 words or fewer).

Title of article, book or speech (if any) featuring or discussing the candidate’s innovative idea:*

Name of author of article or book:*

Name of publication in which the article was printed:*

Publication date of article or book, or date of speech:*

Please provide any other comments regarding the candidate’s contribution to the discourse on regulatory reform.

If you have any problems with submitting your form or have any questions, please contact RegulatoryInnovationAward@mofo.com