FOUNDATION FOR GENETIC TECHNOLOGY

Purpose: To honor an outstanding technologist (must be AGT member).

Eligibility:

1. Technologist must be NCA certified or eligible.
2. Have three or more years of experience.
3. Nomination by peer with support from director (both AGT members).
4. Contributes above what is required by the job description.
5. Demonstrates excellent customer service (internal and external).
6. Demonstrates excellent character:

a. Team player

b. Dependable

c. Detail oriented

d. Focused

7. Demonstrates leadership ability

a. Participates in training

b. Has excellent troubleshooting skills

c. Participates in poster/presentations for lab or meetings

 

Due Date: Monday, February 5, 2007

Mail To: Foundation for Genetic Technology

Outstanding Technologist Grant

P.O. Box 625

Biloxi MS 39533-0625

Section I: Biographical Information (Nominee)

Name_____________________________________________________________

Last First Middle Initial

Address___________________________________________________________

____________________________________________________________

Phone Number________________ Social Security Number_________________

Years of Cytogenetics Experience______ Current Position_________________

On a separate piece of paper list all positions held in cytogenetics, years in those positions and the laboratory OR attach a current copy of your CV.

 

E-Mail Address________________________ AGT Member #_______________

NCA Certification #____________________ (please enclose a copy of the card)

Date of Initial Certification____________________________________________

If Not Certified NCA Eligible Yes______________ No____________________

Section II: Nominator Information

Use an attached sheet to submit a one page essay stating why the individual deserves the Outstanding Technologist Grant using examples of outstanding performance, leadership abilities, etc. This essay should be endorsed by the laboratory director as well as the nominator.

Nominators Name___________________________________________________

Nominators Position_________________________________________________

 

Nominator Address__________________________________________________

__________________________________________________

 

 

Phone #______________________ E-Mail Address______________________

Relationship to the Nominee___________________________________________

Nominator AGT Member #___________________________________________

Section III: Certification Statement

I affirm that, to the best of my knowledge, the above statements are correct. I understand that I am responsible for the submission of all required documents within the deadlines. The Foundation for Genetic Technology reserves the right not to process applications to be late or incomplete.

_________________________________________________________________

Nominee’s Signature Date

__________________________________________________________________

Nominator’s Signature Date

__________________________________________________________________

Laboratory Director’s Signature Date

Laboratory Directors AGT Member #___________________________________