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Application Form - Prix Galien Africa

Application Form


    Information on the main applicant

    Date of birth



    Your country

    In what capacity is the application submitted ?



    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




    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 (maximum one page)

    CV (maximum two pages) and legalized copy of diplomas for individual applications

    Summary of the institution description for institutional applications (maximum one page)

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

    Marketing authorisation for the product or device

    Other relevant document :