LAST DATE FOR RECEIVING NOMINATIONS – 31 DECEMBER 2012

Completed Nomination forms to be sent to:
Ms Akhila Ramesh, Confederation of Indian Industry, Southern Regional Headquarters,
Prof C K Prahalad Centre, No. 98/1 Velacherry Main Road, Guindy, Chennai – 600 032
Tel : 044 – 42444555 | Fax : 044 – 42444510 | Email : | Web : / Criteria for Nominations:
First Generation
Should be registered & functioning in India
Truly Emerging
Minimum 2 years & maximum 10 years in Business
Rs. One Crore to Twenty Five Crore Turnover
  1. Nominee Details :

  1. Name :
/
  1. Designation :

  1. Name to be used on published materials :

  1. Company Information :

6. Company’s full Legal Name :
7. Address
8. City / 9. Pincode / 10. Email :
11 (a) Tel : / 11 (b) Fax : / 12. Company Website :
C. Nominee’s Contact Information :
13. Executive Assistant / Secretary :
14. Tel : / 15. Fax : / 16. Email Address :
  1. General Information :

17. Brief, but specific, description of the business. Include primary products / services.:
18. In which year was the company founded ? / 19. In which year did the nominee assume leadership ?
  1. What percentage of the company does the nominee currently own ?

  1. Has the nominee or the nominee’s business been subjected to an investigation by a government today or a criminal charge in the last 5 years ?  Yes  No
If yes, please attach a separate statement describing details.
  1. Is the nominee still actively involved in senior management?  Yes  No

  1. Please provide the last three years turnover and attach the copy of the financial statements

  1. In your own words, briefly state why you should be considered for this award. (in 100 words)

Declaration :
To the best of my knowledge, the information provided herein is true and complete. All information provided in the nomination form remains confidential to CII and the Juries. I understand that the information provided in this nomination form will be used by CII and the independent jury panel in selecting award recipients and I consent to the use of such information for such purpose. I understand that CII reserves full discretion on the usage of the submitted materials and reserves the right to make amendments as it deems necessary. I further consent to my name, my company’s name, non-financial information, photographs, video recordings and audio recordings of me from whatever source to be used for promotional purposes throughout the “Emerging Entrepreneur Award. I agree that no compensation shall be payable to me or my company for such usage.I agree to use the name “CII” when referring to the award and to otherwise co-operate with CII in promoting the Award.In the event that I am an award recipient. I understand that CII reserves the right to invalidate the award given to me should there be any significant misconduct or non-legal acts on my part.
Nominee’s Signature ______Date : ______
  • Check list for submission (submitted materials will not be returned)
  • Duly completed and signed nomination Form
  • Please send the following materials in 1 DVD
  • Audited financial statements for the three most recent financial years
  • An executive summary of approximately 200 words on the nominee to be used for media and promotional purposes; should include an overview of the nominee and should focus on his / her growth as an entrepreneur and achievements.
  • High resolution (300 dpi or more), passport photo of nominee; should be good business-style shot against a solid background
  • Business card
  • Marketing collaterals / Brochure of your company

The information provided in this nomination form will be strictly confidential and will be used only by CII and the jury in the selection process