1. 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:

2. Primary Activity Why did you choose this activity and location

3. Other Activities Area of Operation (States / district) Populations or individuals served, and how they benefited

4. YearDetail of Work ( 3/ 4 points for each year Max) 2013 2012 Details of work/ programs of the last 5 years ( Annual)

5. YearDetail of Work ( 3/ 4 points for each year Max) 2011 2010 2009 Details of work/ programs of the last 5 years ( Annual)

6. 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)

7. Collaboration with other organizations / Individuals Recognition/ Achievement Future Plans

8. 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.