Nominations

What is the legal structure of the nominee's business? (Please tick) Public Company Private Company Partnership /Unincorporated

Financial Performance Facts:

	Most Recent Year End	2nd Most Recent Year End
Financial Year End (DD/MM/YYYY):
Total annual sales(USD):
Number of Employees::

Has the company merged with, or acquired, another company within the past three years? If Yes , in which Year:

Declaration

The information provided is true and complete to the best of my knowledge. I agree that, if I am selected as a finalist or award recipient, I hereby authorise the release and use of, in US and abroad, in connection with the The Technology Headlines programme, my name, business name, likeness, recording of my voice and photographs including videotapes or other forms of media, which may be taken of me. All financial information contained herein shall not be made public unless I agree to its release.

Do you agree with the above declaration? (Please tick if Yes)

Nominator: (If other than Entrepreneur)