Friends
I have been requested to post this nomination form.
Regards
Harish Kotian
Text follows:
NAB- DEPARTMENT OF WOMEN'S EMPOWERMENT
THE NEELAM KHURSHED KANGA MEMORIAL AWARD-PROFORMA
(OPEN FOR VISUALLY CHALLENGED WOMEN ONLY)
NAME:
FULL ADDRESS:
TEL.NO.WITH STD CODE NO: RESIDENCE:
OFFICE:
MOBILE NO:
E MAIL ID:
DATE OF BIRTH:
CAUSE OF BLINDNESS:
AT WHAT AGE THE DISABILITY OCCURRED:
STATUS OF VISUALLY CHALENGED: TOTALLY BLIND LOW VISION
FIELD AND NATURE OF ACHIEVEMENT:
PRESENT POSITION:
FAMILY BACKGROUND:
DETAILS OF EDUCATION:
A. QUALIFICATION:
B. VOCATIONAL TRAINING:
DETAILS OF EMPLOYMENT:
A. SELF-EMPLOYMENT:
B. SERVICE:
SIGNIFICANT CONTRIBUTION TO THE WELFARE OF THE BLIND / OTHER DISABLED SECTOR:
(Kindly attached extra sheets if required)
DETAILS OF ANY SIGIFICANT ACHIEVEMENT BESIDE THE ABOVE:
(Kindly attached extra sheets if required)
*LETTER OF RECOMMENDATION HIGHLIGHTING = NOMINIES ACHIEVEMENT
*COPIES OF CERTIFICATES TO BE ATTACHED
NAME AND ADDRESS OF THE HEAD
OF THE
INSTTUTION/NAME AND
ADDRESS OF THE SPONSORING
AGENCIES (WITH RUBBER STAMP)
To be filled in and return latest by 15th November 2013
*NB: No nomination will be considered without this letter, passport size
photograph and copy of Certificates.
Please mail to the address given below:
National Association for the Blind (I)
124 / 127, Rostom Alpaiwala Complex,
Near Reay Road Railway Station,
Reay Road (East)
Mumbai 400 033.
022 - 655 146 04 /10
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