Application for the nomination

Mexico: +52 558 526-60-31
UK: +44 204 577-36-57
mexico@iventu.co.uk
45 Fitzroy Street, Fitzrovia London, W1T 6EB, United Kingdom

Applicant’s details

Details of the person who is submitting the application

Applicant's name and surname*

Name, Patronymic name Surname

Company name*

Applicant’s job title*

Work phone number*

(with country and city code)

Mobile phone number*

(with country and city code)

Email*

Nominated company details

Сompany’s head*

Company top manager’s name Company top manager’s surname

Company name*

Top manager’s job title*

Website URL*

Information about the company*

(no more than 150 words)

Company logo

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

Application for a nomination

A company can participate in maximum 3 nominations.

I would like to submit application in*

One nomination

Two nominations

Three nominations

First nomination

Please select the nomination*

Nominee’s name and surname*

Name, Patronymic name Surname

Company name*

Job title*

Work phone number*

(with country and city code)

Mobile phone number*

(with country and city code)

Email*

Please provide information about the results achieved by your company, your representatives and implemented projects*

Description should include no more than 300 words

Second nomination

Please select the second nomination*

Nominee’s name and surname*

Name Surname

Company name*

Job title*

Work phone number*

(with country and city code)

Mobile phone number*

(with country and city code)

Email*

Please provide information about the results achieved by your company, your representatives and implemented projects*

Description should include no more than 300 words

Third nomination

Please select the third nomination*

Nominee’s name and surname*

Name, Patronymic name Surname

Company name*

Job title*

Work phone number*

(with country and city code)

Mobile phone number*

(with country and city code)

Email*

Please provide information about the results achieved by your company, your representatives and implemented projects*

Description should include no more than 300 words

Company representative

Contact details for the company’s representative who is responsible for communication with the “Ukrainian Pharma Inspiration Awards” organising committee

Company representative's name and surname*

Name, Patronymic name Surname

Job title*

Email*

Work phone number*

(with country and city code)

Mobile phone number*

(with country and city code)

Final step

Are you a human?