NATIONAL CENTRE FOR PROMOTION OF EMPLOYMENT FOR DISABLED PEOPLE
E - 150, EAST OF KAILASH, NEW DELHI - 110 065
Tel.: 011-26221276 / 26221277 / 49122868; Fax: 011-26221275
Email:
NOMINATION FORM - INDIVIDUAL THE NCPEDP-MINDTREE HELEN KELLER AWARDS 2017
*Please read the instructions given at the end of the form
DETAILS CONCERNING THE NOMINEE:
Name:Whether a person with disability?YES/NO:
If yes, nature and extent (percentage) of disability?
Category under which nominated (please tick the relevant category):
Category A: Role Model Persons with Disabilities: Persons with disabilities from within the disability sector and outside who have been active as ambassadors of the cause of employment for persons with disabilities and are a positive role model for others (3 Awards).
Category B: Role Model Supporters of Increased Employment Opportunities for Persons with Disabilities: Individuals from within the disability sector or outside who have contributed substantially to the cause of promoting employment opportunities for persons with disabilities over an extended period of time (3 Awards).
Address:
Telephone No(s).:
E-mail ID(s):
Date of Birth:
Educational Background:
Name of the Organisation:
Job Title/Designation:
Specific Area of Work in not more than 200 words:
Synopsis of the work done (specific to the cause of employment of persons with disabilities - DIRECT) in not more than 700 words:
Specify the duration of the work analysis given above:
Specify the number of people with disabilities impacted by the work mentioned above:
Synopsis of work done (INDIRECTLY contributes to the employment for persons with disabilities like education, etc.) in not more than 200 words - OPTIONAL:
Specific Achievements in not more than 300 words:
Has the nominee won the NCPEDP Helen Keller Award earlier? If yes, specify the year and mention how she/he has escalated her/his efforts since then towards the promotion of employment for person with disabilities (in not more than 300 words):
Details of any other awards/recognition received in not more than 300 words:
DETAILS CONCERNING THE NOMINATOR:
Name:Job Title/Designation:
Name of the Organisation:
Address:
Telephone No.: / Fax No.:
E-mail:
What is your association with the nominee and for how long have you known her/him? Please describe in not more than 250 words.
What is your perception of the nominee’s future role with regard to promotion of employment opportunities for persons with disabilities? Please describe in not more than 250 words.
What are the personal traits that the nominee possesses that set her/him apart and make her/him a role model? Please describe in not more than 250 words.
State briefly (in not more than 250 words) your reasons for nominating the person:
DATE: / SIGNATURE:
Thank you for helping us identify a possible role model. We will be grateful if you could please e-mail this Nomination Form at your earliest convenience, but not later than Saturday, 30th September, 2017.
You are requested to enclose with the form:
- A recent passport size photograph of the nominee.
- Copy of the disability certificate (if applicable).
- Any other documentation (not more than 5) that may help us in the selection process.
Please pay a close attention to the various word limits specified for each section of the Nomination Form. Any violation of the said limit/s would automatically disqualify your application.
Please make sure that you send us the completed Nomination Form in word or pdf format only. Do not send hard copies or scanned copies as they are not accessible to people with visual impairment. Supporting documents can be scanned and sent with the form.
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NOMINATION FORM: THE NCPEDP-MINDTREE HELEN KELLER AWARDS 2017: INDIVIDUAL