Nomination Form

Plan India Impact Awards 2024

Nomination Form Fill all form field to go to next step

  • Section 1
  • Section 2
  • Section 3
  • Section 4
  • Section 5

Nomination and Award Category

Step 1 - 5

Nominee Details

Step 2 - 5

1. Best Child Welfare Committee / 2. Best Women’s Self – Help Group

S. No. Question Response
1 Name of CWC / SHG
2 Registration / Legal Status (for SHG)
3 Total functional years
4 Name of the Chairperson / Head
5 Mobile number of the Chairperson / Head
6 E-mail ID
7 Full address
8 District
9 State
10 Have you received any other awards?

Self-nomination

S. No. Question Response
1 Please provide details of references (in case of self-nomination) Reference 1
Full name
Contact number
E-mail ID
Organization
Designation
District
State
Relationship with the nominee
Reference 2
Full name
Contact number
E-mail ID
Organization
Designation
District
State
Relationship with the nominee

Details of “Individual / Group / Institution” or “Plan India personnel” nominating the applicant

S. No. Question Response
1 Name of individual (nominator)
2 Name of organization / group / institution (Please mention “Plan India” if you are a person / team in Plan India)
3 Designation
4 Contact number
5 E-mail ID

Application Form

Step 3 - 5

S. No. Question Response
Impact
1 Number of people benefitted / sensitized (Target groups)
2 Number of girls / women benefitted / sensitized (Last Mile Champion for Girls’ Rights Award Category)
3 Geographical coverage 1. Number of village(s)/ slums
4 Name of the Block(s)/Municipal Wards
5 Name of the District(s)
6 Name of the State
7 Source of funding (Indicate the funding source if any)

Innovation
8 Narrate how you used innovative technique(s) to improve efficiency, and address issues and real-time challenges in the course of work. Provide your explanation (max. 300 words).
Inclusion
9 How has the nominee's work promoted social inclusion and equality? Provide your explanation (With examples of indicators used) (max. 300 words).
Story of change
10 Narrate a story of change wherein you have contributed to bringing positive change in the community. Provide your explanation (With examples of indicators used) max. 300 words).
11 How does the nominated applicant plan to carry forward the initiative (including a scaling and/or sustainability plan)? Provide your explanation ((With examples of indicators used) max. 300 words).

Document Upload

Step 4 - 5

S. No. Supporting Materials outlining results and impact List
1 Certificates
2 Letters of Recommendation
3 Media Coverage
4 Case Studies
5 Project Reports
6 Testimonials from Beneficiaries
7 Photographs, videos, or other media showcasing the impact
8 Publications/ News paper clippings outlining results and impact
9 Reports or studies conducted to evaluate the impact
Story of change
10 Provide up to 10 links, with a brief description– (Exclusively for the nominees of the Radhika Sen Memorial Awards)

Declaration

Step 5 - 5

Declaration

I, the undersigned, hereby declare that:

  • The information and data provided in this nomination form are true and correct to the best of my knowledge.
  • The information provided in the nomination form has been duly vetted and verified.
  • I grant Plan India the right to use the information and data provided in this form for Award promotion, communication, and record-keeping purposes.
  • I confirm that there is no association with any political parties and/or religious groups.
  • I understand that any false information or misrepresentation may result in the disqualification of the nomination.
  • I agree to provide any additional information or documentation that may be required to support this nomination.
  • I understand that the decision of the Plan India Impact Awards jury is final and binding.
  • I consent to Plan India conducting background checks and verification processes as part of the evaluation of this nomination.
  • I agree that, I am not selected for the Award I will accept the jury’s decision and will not challenge their decision in any form.
Do you agree?
Full name
Date
Place

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