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Application Form/Data Information Sheet

Application Form

This part is to be filled up by all applicants for the recognition – direct applicants as well as nominees.

    1.  I, am hereby applying for the mentioned recognitions indicated below:
    List of Recognitions {Please tick one}

    2.  Details & Achievements of the Applicant/Nominee for the recognition. Please feel free to attach any supporting documents.

    # Item Details/ Description
    2a Full Name
    2b Address
    2c Email id
    2d Mobile #
    2e Organization Type

    (Please Tick one)
    2f Achievements.

    Please describe in about 1000 words the key achievements over the past 5 years.

    2g List the awards and recognitions received in the past 5 years 0
    2h List the significant entities and individuals that you have worked with towards your achievements 0
    2i Describe significant media coverage on you / your organization /your achievements. 0

    2j Have you received any award from Rotary earlier? If yes, please describe 0
    2k Have you or your organization been funded at any time for any purpose? Please describe 0
    2l Has your work been documented or published in any relevant journal or forum? Please provide details 0
    2m Please provide copies of documentation as applicable for the award being applied for, as per attached checklist in ‘Part B’.

    2n Please provide two references in your area of Operation with whom we could interact. Reference #1

    Reference #2

    2o Any Other Information: Please feel free to provide any other information in support of the application. 0
    2p Please sign the declaration format as indication at the end of ‘Part B’ Upload from "Signature" section below.


    I/We hereby declare the following:

    6) All information supplied by us is true and correct to the best of our knowledge.
    7) We have not withheld any information that can have an impact on the evaluation of the recognitions.
    8) There are no legal or criminal proceedings against me/us.
    9) I/We have not been convicted for any offence by any court of law.




    You can download form & fill the required details and send a email to “”