IMC Inclusive Innovation Awards, 2012 Participants details Name of the Organisation / Individual Authorised representative – Name and Designation (applicable incase of Organisation) Title Office / communication address Organisation Incorporation Date Landline Number. Mobile Number Email address Number of employees Organisation website Social media link (facebook, twitter, youtube etc)

IMC Inclusive Innovation Awards, 2012 Innovation details Is the product/ service already launched in the market? (If yes, then answer the below questions) Provide date of launch? Markets where it is launched? Is it currently available? How is the project funded?

IMC Inclusive Innovation Awards, 2012 Innovation details Opportunity identified (Should mention details about opportunity identified in the market, current competition, market size, details of product / service offered etc)

IMC Inclusive Innovation Awards, 2012 Innovation details Why it is inclusive innovation (impact / potential impact on society at large)

IMC Inclusive Innovation Awards, 2012 Innovation details Do you think the business model is sustainable

IMC Inclusive Innovation Awards, 2012 Innovation details Is this business model replicable (should write about market expansion)

IMC Inclusive Innovation Awards, 2012 Innovation details Applicants may attach the following documents. (Product image / brochure, Write-up / Publication, Awards / Certificates / Recognitions )

IMC Inclusive Innovation Awards, 2012 Declaration I/We confirm that we possess requisite intellectual property rights to the material/data/information submitted as also to the product/service submitted for consideration of the Award. By making this application, I/we, grant requisite license/permission to IMC to announce, display, project the applicant/awardee and the product and/or service, as the case may be, and take all steps considered appropriate by IMC, in their sole discretion. I/We confirm that the decision of Jury/IMC shall be final and binding in this regard. I/We have read the Terms and Conditions of the Award and accept the same. __________________ (Authorised representative*) Name: _____________________________ Designation: ________________________ E Mail: _____________________________ Contact number: _____________________ * Please sign incase of hard copy submission

IMC Inclusive Innovation Awards, 2012 Note: Receipt of entries after last date of receipt specified may be permitted only at the discretion of the Awards Management Awards Management will not be responsible for application forms that are lost in transit / received late If Applicant desires to send the entry in hard copy, that should be submitted to IMC’s Office at Churchgate, Mumbai in an envelope marked “ IMC Inclusive Innovation Award, 2012”. The Application Form needs to be completed and signed by the individual submitting the application and in case of application by an organization, it must be signed by senior officer of the organization (from amongst the MD, CEO, COO, CFO, Chairman, Directors, Partner, Trustee,etc.) Incomplete Application Forms received through any mode will disqualify the Applicant from participating in the Awards Entries will be accepted in English only Disqualification of entries received is at the sole discretion of Awards Management, on a case by case basis