Award Nomination Form Select Application Type Government PSU Corporate Corp. Foundation NGO MSME Individual Start-up CSR Professional Others Select Award Category CSR Leadership Award Best Innovative CSR Project Award Best CSR Leader Award Best CSR Impact Award Best NGO of the Year Award (Non Govt Organization) NGO Leadership Award (Non-Govt Organization) CSR Professional Award (Non-Govt Organization) Basic Information Name of the Organization Company website URL Date of incorporation Full Address State Pin code Nature of the business & its products/services Contact Details Name of the Organization’s Head Head’s Designation Head’s Email Head’s Phone Name of the CSR Head CSR Head’s Designation CSR Head’s Email CSR Head’s Phone Name of the Officer handling this award Officer’s Designation Officer’s Email Officer’s Phone Select Project Category Eradicating extreme hunger and poverty Promotion of education Promoting gender equality and empowering women Reducing child mortality Improving maternal health Combating human immunodeficiency virus, acquired, immune deficiency syndrome, malaria and other diseases Ensuring environmental sustainability, Employment enhancing vocational skills, social business projects healthcare rural development, sustainable agriculture Contribution to the Prime Minister’s National Relief Fund or any other fund set up by the Central Government or the State Governments for socio-economic development Relief and funds for the welfare of the Scheduled Castes, the Scheduled Tribes, other backward classes, minorities and women and such other matters as may be prescribed About the Project / project for which award is being claimed Name of the Project Period of Operation of Project Location/s of Project No. of Beneficiaries for the Year Details of Project (maximum 200 words) Project Cost One Time Project Cost Operational Cost of Project Nature of Outcome / impact on the beneficiaries – explain in 200 words Short term impact Long term impact Sponsor of the project Name of the Sponsor Address of the Sponsor Contact Numbers Email Id Website URL Attach details in separate sheet for following, if applicable Any other award/s received for this project Comments of the beneficiaries of the project Name of the executing agency of the project. If done by an NGO, please mention the details along with their scope of work and responsibility in about 100 words Submit report of impact assessment, if executed by any third party for this project (in max. 200 words) Any additional information Please note nominations submitted with incomplete form, in respect of information sought and/or non-payment of nomination fees will be rejected. Undertaking I/We hereby declare that all the information given above is true and correct to the best of my/our knowledge. I/we understand that this application shall be processed by a team of the experts and placed before the jury. Additional information as required by the jury will be furnished by me/us in a particular time frame. If required, I/we shall attend a meeting with the Jury about my/our nomination. Submit
