Section 1 – Nomination |
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Nomination by |
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Section 2 – Nominee Details |
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Name |
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Year of birth |
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Years of service |
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Primary phone number / Secondary phone number |
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E-mail id |
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Full address |
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Pincode |
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Have you received any other awards? |
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If you have answered “Yes” above, please provide the name of the award, name of the awarding body / institution and year. |
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Online Presence (Provide links, if any) |
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Passport size photo |
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Section 3A – Please provide details of references |
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Section 3B – Please provide details of nominator |
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Name of individual (nominator) |
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Name of Organisation / Group / Institution |
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Designation |
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Contact number |
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E-mail ID |
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Section 4 – Nomination Form (Please provide information for the last 12 months) |
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"If you face any difficulty filling out Section 4 of the form, you can print it, complete it manually, and then upload the duly filled form using the upload button."
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Number of people benefitted / sensitised |
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Describe the target groups benefitted / sensitised with age and gender segregation. |
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Details of geographical coverage: |
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Narrate how did you create an exemplary and lasting impact on individuals or groups under challenging and adverse circumstances? How did you demonstrate an exemplary processes to bring about positive changes in children’s growth and development, adolescent girls and women. Justify (max 300 words) |
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Narrate how you used innovative technique(s) to improve efficiency to address issues and real-time challenges in the course of work (max 300 words) |
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Narrate a story of change wherein you have contributed to bringing positive change in the community. Justify (max 300 words) |
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Section 5 - Upload Document |
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Section 6 - Declaration |
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I hereby declare that the information given above and in the enclosed documents is true to the best of my knowledge and belief.
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