CII Foundation Woman Exemplar Award 2014

Please do not fill this form for submission. This is only for reference to help you collect your answers and to get ready to fill the online form at

GuideStar India invites you to nominate your outstanding grass-root social worker for the CII Foundation Woman Exemplar Award 2014

GuideStar India is pleased present the Confederation of Indian Industry's (CII) 10th edition of the CII Foundation Woman ExemplarAwards.Institutionalized in 2005, the award promotes women empowerment at the community level bydiscovering and recognizing those who have, against all odds, excelled and contributed significantlyto the development process in India.The Award is conferred on women working at the grass roots level who have contributed significantlyin the fields of:• Education & Literacy• Health• Micro EnterpriseSteps to apply for the award: (i) Complete this application form. It is a short form that should not take more than 30 minutes. In this form, there is an option to save and continue later. Please use this option if you are unable to complete the form in one sitting. After you click Save & Continue later,please wait for the screen to display a form where you need to provide your email id at which you will receive an email with the link to complete the form whenever you want. If you do not provide your correct email id and receive the link to continue, you will have to apply afresh.To Download the blank form for reference, click here. Use this form only to collect information and prepare for filling the online form.(ii)After submitting the online form, please send by email or courier the following directly to CII clearly stating organisation name, GSN and IT PAN2 passport size photographs of the Nominee2 passport size photographs of the ProposerClick and Download the Recommendation Letter (Annexure A) Photographs of the nominee engaged in activities, if anyNews clipping/articles, and other such items, if anyYou need to send the above documents by email to or by post/courierto Ms. Mitali Ghosh, Development Initiatives, The Confederation of Indian Industry,Plot no. 249 – F, Sector – 18, Udyog Vihar, Phase – IV, Gurgaon 122015.Please do not send these to GuideStar India as such documents will not be accepted.The closing date for this application form is 31st December.

1. Please select the sector under which you would like to apply for CII Foundation Woman Exemplar Award *

If your organization works in more than one of the areas below, pick the one that you feel is most applicable

2. Name of the Organisation *

Please mention registered name of the organisation

3. Organisation's IT Permanent Account Number (IT PAN) *

Please ensure all 10 characters are entered correctly. For example, AABTC0541K. Please do not leave any space between or after characters

4. If registered with please provide your organisation’s GuideStar Number (GSN) *

If you are not registered with GuideStar India, please write NA. If you are registered with GuideStar India and do not remember your GSN, please look for it in the mailer you received.

Proposer Form

5. Name of the Proposer *

6. Affiliation *

State how the proposer is connected with the Nominee

7. Correspondence address of your organisation *

7.1. District *

7.2. PIN *

7.3. State *

8. Office Telephone number *

Please ensure all digits are entered correctly including STD code. For example 022-26858900

022-26856900

8.1. Residential Telephone number *

Please ensure all digits are entered correctly including STD code. For example 022-26858900

022-26858900

8.2. Fax number*

Please ensure all digits are entered correctly including STD code. For example 022-26858900

022-26856900

8.3. Mobile number *

Please ensure all digits are entered correctly. For example 9812345678

1234567890

8.4. Email ID (if any)*

Please double check that your email id is correct, and please ensure that you check mails daily for any important communication from us.

9. Brief Profile of the Proposer *

PLEASE NOTE: IF YOUR FORM IS INCOMPLETE, YOU WILL SEE RED BORDERS AROUND ITEMS YOU NEED TO FILL AND RESUBMIT

Page 2

NOMINATION FORMSection I: Personal details of the nominee

Name*

Address *

District*

PIN*

State*

Telephone*

Please ensure all digits are entered correctly including STD code. For example 022-26858900

Mobile*

Please ensure all digits are entered correctly. For example 9812345678

Email ID (if any)*

Is the nominee a recipient of any other award(s)*

Name of the Project the Nominee is associated with*

Location of the Project*

Duration of the Project*

PLEASE NOTE: IF YOUR FORM IS INCOMPLETE, YOU WILL SEE RED BORDERS AROUND ITEMS YOU NEED TO FILL AND RESUBMIT

Page 3

Nomination form: Section II: Details of the Project

Name of the Project *

What prompted the nominee to launch the project *

When was it launched and where *

Who helped her to launch the project *

How is the project being carried out*

Who are providing resources for the project*

Who are the beneficiaries of the project*

What are the benefits accrued*

How is the project monitored and evaluated*

Any recognition by Government or other agencies given to this effort*

Nomination Form: Section III: Information supporting the following award assessment criteria:

Key Achievements*

Unique approach adopted to achieve desired results*

Beneficiaries Targeted*

Information about Upgrading Knowledge and empowering others*

Vision and Leadership*

Declaration: I declare that I am authorised by my organisation's management to submit this application. I confirm that all information provided in the form are true and correct.Nomination form with all the information, must reach CII latest by December 31, 2013.

Variable / Response
Declaration: I declare that I am authorised by my organisation's management to submit this application. I confirm that all information provided in the form are true and correct.Nomination form with all the information, must reach CII latest by December 31, 2013. | Name of the person filling the form
Declaration: I declare that I am authorised by my organisation's management to submit this application. I confirm that all information provided in the form are true and correct.Nomination form with all the information, must reach CII latest by December 31, 2013. | Designation
Declaration: I declare that I am authorised by my organisation's management to submit this application. I confirm that all information provided in the form are true and correct.Nomination form with all the information, must reach CII latest by December 31, 2013. | Email Id of the person filling the form

PLEASE NOTE: IF YOUR FORM IS INCOMPLETE, YOU WILL SEE RED BORDERS AROUND ITEMS YOU NEED TO FILL AND RESUBMIT

Please do not fill this form for submission. This is only for reference to help you collect your answers and to get ready to fill the online form at