CIPS | Nomination Form

Nomination Form

1. Details of the Applicant (Individual / Organisation)

Name:
Designation:
Type of Institution:
Name of the Department / NGO / Private Organisation:
Contact Address (Postal):
eMail:
Mobile:

2. Name of the North Eastern / Hill State / Union Territory:

3. Title of the Innovation / Innovative / Best Practice:

Time Period:

From:

To:

4. Segment of Innovation:

Education
Environment
Health
Information Technology
Rural Development

5. Location (City; Village; District; State):

City:
Village:
District:
State:

6. Key Products/Services etc.:

7. Information about the Scenario prior to the Innovation / Best Practice:
(Trigger for the Innovation / Best Practice)
(about 400 – 500 words)

Number of words:

8. Details of the Innovation / Best Practice:
(Unique features, Illustration, Application in the area)
(about 500 words)

Number of words:

9. Challenges Encountered:
(about 300 words)

While developing the innovation:
While implementing the innovation:

10. Strategy Adopted for Implementation of the Innovation:

Physical:
Financial:
Technological/IT:
Social:
Any Other:

11. Approximate Cost incurred for Innovation in Rupees:

12. Key Beneficiaries/Target groups:

13. Impact of the Innovation:

Social:
Technological/IT:
Financial:
Environment:
Policy Changes:
Others:

14. Status:
(Before and after implementation of the innovation)

Before Implementation:
After Implementation:

15. Details of Replication in other locations /states/districts, (If any) :

16. Was this initiative recognised under any other award scheme?

If yes, please provide details (not more than 400 words)

17. Other Information

Certificate (max 1mb)
Photographs (max 1mb)
Video Clippings (max 1mb)
Press Clippings (max 1mb)

Note: If you wish to provide any additional information, please send it in a Pen drive/CD/DVD along with the hardcopy by post.

Certificate (max 1mb) Only JPEG, JPG, PNG formats allowed
Recognition (max 1mb) Only JPEG, JPG, PNG formats allowed
Photographs (max 1mb) Only JPEG, JPG, PNG formats allowed
Video Clippings (max 1mb) Only MPG, MPEG, MP4, WMV, MOV, AVI formats allowed
Press Clippings (max 1mb) Only JPEG, JPG, PNG formats allowed

18. Reference (one):

Declaration by the Project Head/Owner of the project/Team members / Individuals / Private Organisation / NGOs nominated for the CIPS awards:
I/We hereby declare that the particulars furnished above are correct and true to the best of my/our knowledge. I/we have gone through the information on the awards scheme published in the website of the Centre for Innovations in Public Systems www.cips.org.in and agree to the terms and conditions given there in. I/We shall abide by the decision of the jury for declaration of the award.

Awarding Innovations

Nomination Form