1. Name of Nominee : ____________________ Category : _____________________________
Date of Birth
Are you affiliated with any organization
Yes No
If yes: Name of Organization ______________
Designation : ______________________
Address
Referees Details ( 2)
Name 1 :
Organization:
Relation to the Nominee:
Name 2:

2. How many years have you been working in this field
Describe the nature of your work ( location, speciality, activities etc.)
How many years have you been working in this field

3. If affiliated with any organization
(if applicable)
Organization :___________
Designation : ___________
Responsibilities : ___________________
Impact of the activity
( can include patient success stories)
People helped in the last 5 yrs

4. Main source of funding
Collaboration with other organizations / Individuals
Recognition/ Achievement

5. Any other information you would like to share
A brief (500 words max) describing your contribution in respect to the specific category you have nominated yourself.
Any other information you would like to share