IMC Inclusive Innovation Awards, 2017 Application Form GEN – Z Category ( Age Group : 13 to 23 Years )

IMC Inclusive Innovation Awards, 2017 Guidelines: Fill in the form just as you would on paper, by typing your information in the supplied fields. If the space is inadequate in any field, please add supplements. Please fill all information with complete accuracy and to the best of your knowledge. Please provide most latest data / information. You may use bullet points, diagrams, charts and other data as appropriate. You may save your application to your local drive or directly on a USB key, at any time, without being connected to the Internet while filling the Form. Do make sure that your email addresses are correct and that your accounts are not over quota; the IMC Inclusive innovation Cell will be sending you all communications on the email address provided by you in the Application Form. 6. Please read the Notes to this Form as also IMC Inclusive Innovation Awards, 2017 Brochure for more information and guidance.

IMC Inclusive Innovation Awards, 2017 Notes: 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, 2017”. The Application Form needs to be completed and signed by the individual submitting the application and in case of application by Company, it must be signed by Director of the Company. Incomplete Application Forms received through any mode will disqualify the Applicant from participating in the Awards. Disqualification of entries received is at the sole discretion of Awards Management, on a case by case basis.

IMC Inclusive Innovation Awards, 2017 A: Applicant Details Name of Applicant Name of Company and date of incorporation, if company is formed Name of the Founder (s) if it is different from the Applicant Date of Birth of Applicant :   No. of Employees (if applicable) : Office / Communication Address: Web Address: Whether associated with any Organisation / NGO / NPO / Government Organisation – Which one and the nature of relationship? Stage of Education of the Applicant ( School, College, Post Graduation, Completed) Educational details the Applicant Experience of the Applicant

IMC Inclusive Innovation Awards, 2017 B: Product/Service details: Describe product/service that the Applicant has developed/designed or is working on, giving nature of the product/service, its unique features as also stating why the Applicant considers that it meets the criteria of inclusive innovation Is similar product/service available anywhere in India/abroad and is the product/service an improvement or cost efficient version of that? If so, provide details of the same. Has Applicant submitted this product/service proposition to any other institution/organization for consideration of grant/award, etc.   If so, provide status of the same Has the Applicant worked on or developed any other product or service and what is the status of the same currently Has the Applicant won any awards or received any grants till date? If so, provide details thereof

IMC Inclusive Innovation Awards, 2017 C- Product Design / Brochure / Pictures / : Please attach

IMC Inclusive Innovation Awards, 2017 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. ____________________________ (Signature of the Applicant) * Please sign incase of hard copy submission or provide digital signature