Application Form

    Prefix

    Information on the main applicant


    Date of birth


    Sex

    Nationality


    Your country


    In what capacity is the application submitted ?

    Type

    Sector

    How did you hear about the Prix Galien Africa ?

    Name of the project / Product / Applicant

    Date of the Marketing Authorisation (MA) dating from December 31, 2016 at the latest




    Is it a team effort ?



    Date of birth


    Sex

    Nationality


    Country




    What sector are you working in ?

    For which award category are you applying ?

    Description of the innovation and /or discovery

    How does it contribute to the improvement of the human condition ?

    What is its impact on the African continent ?

    Documents to be attached :

    Application letter

    CV and legalized copy of diplomas for individual applications

    Présentation complète de l'institution pour les candidatures institutionnelles

    Full description of the product or device and its impact on the African continent (maximum three pages)

    Marketing authorisation for the product or device

    Other relevant document :