Nomination Registration 2020

  • Nominee Details
  • Proposer Details
Part A
Name of the Nominee: Date of Birth:
Educational Qualification (Please provide the highest qualification attained (for example: 10th Standard, 12th standard, BA, MA etc.)
Language skills (Please indicate the level of proficiency by Ticking in the appropriate box.)
  Language Understand Speak Write/read  
  Hindi Moderate     Fluent Moderate     Fluent Moderate     Fluent  
  English Moderate     Fluent Moderate     Fluent Moderate     Fluent  
  Other (Please specify)
Marital Status
  Never Married Married Widow Separated / Divorced  
Family background (please mention names of family members and their occupations)
Family income (Please provide the income of the family as a whole per month- attach proof)
Contact Address: District:
Pin: State:
Telephone: Mobile:
E-Mail (please provide a valid e-mail ID which is being used by you for checking day-to-day mails)
Have you ever applied for this award before Have you ever been shortlisted as the finalist? If yes,
please mention the year of selection.
  Yes No
Part B : Section I: Information Supporting the Assessment Criteria
Please select the sector under which you would like to apply for CII Foundation Woman Exemplar Program (if your organization works in more than one area, pick up the sector that you feel is most applicable to your work.)

Education Health Micro Enterprise    
Provide a brief description of your work: (when did you start your work and where, details of project/ activities undertaken by you, how is it being carried out, unique approach adopted to achieve desired results, who are the beneficiaries) Give examples, wherever possible.
What prompted you to commence your project activities? How did you decide who you would work with? (Who/what is the source of your inspiration for your project / activities/ choosing the community that you work with?)
What personal challenges / hurdles did you face and how did you overcome them? (Please mention the challenges you face from the family, community, government departments, accessing opportunities and services, any other hurdles?) Give examples wherever possible.
How has the work impacted the surrounding areas/communities especially marginalized groups (give specific and quantitative information, benefits accrued, and transformation in the community/lives of beneficiaries because of your work)? Share examples and case studies wherever possible.
What is the source of support for your project/ activities? (From where do you get resources including finances, space, manpower, any equipment, etc?)
Of all the projects and activities that you lead, what is the most significant intervention that is creating change?
Do you work in a team or individually? If you work with a team, specify the number of team members and their roles (You may choose to depict the same diagrammatically) strength of your team and the challenges you face working with a team. (Please note: The team might be part of the same organization that you work in( paid) or might be members of the community who play leadership roles)
When you think back about your work, what are some of the key realisations about yourself as a leader and a learner? Please give examples.
Where do you aim to take your project in the next five years? (share broad goals, directions and strategies)
How do you plan to carry forward your project/ activities? (If you are willing to scale up your operations/continue them in the future, please provide expansion details)
What are the anticipated challenges for implementing these plans? (Please mention the challenges you may face from the family, community, government departments, accessing opportunities and services, any other hurdles)
Please mention the support required for future expansion (including funding/training/ support from Government or institutions like CII)
Section II: Details of Awards received
Mention all awards received in connection with the current area of operation/project activities

Award Name Awarding institution Year Purpose/domain Monetary value (if any)
Section III: Association with the proposing organization (only organizations can propose)
Mention the nature of your association with the proposer/ NGO. (choose from the options below)

Founded the NGO and directing its activities
Related to the NGO Founder and supporting its activities
Employee of the NGO and taking part in its activities
Beneficiary of the NGO
Any other (please specify)
Attach supporting documents like ID card, NGO registration documents      
Since when have you been associated with the Proposer NGO? (Mention year)

Give details of your roles and responsibilities with respect to your association with the Proposer NGO.
Name of the proposer
Name of the organization
Designation of the proposer in the organization
Please provide specific details about the activities carried out by your organization (briefly mention the areas of intervention, activities undertaken by your organization, target beneficiaries, reach in terms of villages and beneficiaries)
Organization’s Permanent Account Number (IT PAN)
Contact Address (Please provide complete address for correspondence)
District: Pin: State:
Telephone: please ensure all digits are entered
correctly including STD code, for example – 022-858900
Mobile: please ensure all digits are entered correctly
(For example 9812345678)
E-Mail: please provide a valid e-mail ID which is being used by you for checking day-to-day mails.
Provide details of your Association with the Nominee (how do you know the Nominee and about her work)
Give brief overview of the community to which the nominee belongs.
What are the social and economic challenges that your nominee is addressing?
Please assess your nominee on the following skills and share instances where she actively demonstrated the competencies: You may refer to the following skillsets for bringing out her competencies.
Self - driven/ Initiative taking
History of personal transformation, learning and growth
Indomitable spirit/ Risk taking ability
Resourcefulness/ Ability to generate finance, in-kind contributions, volunteer engagement, government support etc from the local environment
Project Management or idea execution ability
People management / stakeholder management.
Ethical leadership/ Role model
Business acumen of the Nominee (under micro-enterprise category).
In what ways does she deserve to be called ‘EXEMPLAR’?
From Nominees:
• 2 passport size photographs of the Nominee.
• 2 passport size photographs of the Proposer.
• Recommendation letter in JPEG or PDF format
• Photographs of the nominee engaged in their activities
• News clippings / articles and other such items, if any
• Proof of family income
• Identity card (in case nominee is an employee of the proposer organization)

From Proposer:
• Organization’s Permanent Account Number (IT PAN)
• NGO registration documents