Organization: __________________________

Category : _____________________________Date of Incorporation/Registration

Registration Number

Date :

No: ____________________

Registered Address

Is the nominee registered with any of the following organizations * Color the box you would like to choose

If yes , please mention registration No. / Name

GuideStar India Give India Samhita Indian Ngos Other __________________   No Yes - Registration No.

Referees Details ( 2) •Name 1 :

•Organization:

•Relation to the Nominee:

•Name 2:

•Organization:

•Relation to the Nominee:

Primary Activity

Why did you choose this activity and location

Other Activities

Area of Operation (States / district)

Populations or individuals served, and how they benefited

Year Direct Beneficiaries Indirect Beneficiaries

2013

2012

2011

2010

2009

Year Detail of Work ( 3/ 4 points for each year Max)

2013

2012

Details of work/ programs of the last 5 years ( Annual)

Year Detail of Work ( 3/ 4 points for each year Max)

2011

2010

2009

Details of work/ programs of the last 5 years ( Annual)

Number of Staff Full time

part time

volunteers)

Ability to scale up and adaptability across geographic and organizational boundaries

Main Source of funding

Details of Past budget ( gross expenditure for last 3 years on primary activity)

Financial Years Total Income (Rs in Lakhs) Total Expenditure (Rs. in Lakhs)

2011 - 2012

2010-2011

2009 - 2010

Collaboration with other organizations / Individuals

Recognition/ Achievement

Future Plans

Any other information you would like to share

A brief (500 words max) describing the organizations contribution in respect to the specific category in which you have nominated yourself.