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Part - I Key Details

Category	:		Theme	:	if others, pl specify:
Type of Environment Communication Initiative	:	if others, pl specify:	Funded By	:
Initiative Title	:
Initiative Start Date	:		Initiative End Date	:

Part - II Description

Initiative Purpose and Goals	:	Description (Please describe in max 250 words the initiative)	:
Target Audience (Please mention the initiative target group)	:	Medium Used	:	if others, pl specify:
Activity Details (Frequency and duration if print or electronic media used)	:	Achievements, Outcomes and Impact considering the evaluation criteria (Achievements: Extent to which initiative goals were achieved; Outcome: Results of initiative implementation; Impact: Initiative influence on target audience) (Submit outreach data, if any, kindly attach relevant documents i.e. activity reports, ppts, documentation, collaterals etc in Part III)	:
Sustainability (How initiative has been sustainable over the years and future sustainability)	:	Elaborate why your entry is a game changer? (Is it innovative? Can it help sensitise & engender positive behaviours? Has it galvanised responsible action for a sustainable future? Kindly attach relevant documents, testimonials etc. if any, to show change effected by initiative in part III).	:

Part - III Documents (upload here)

Photographs (Max 4 photos can be uploaded in jpeg, png and gif formats only)	:	News Coverage (Max 4 news clippings can be uploaded in jpeg, png and gif formats only)	:
Videos (Please paste the film link here i.e. YouTube or Vimeo, etc)	:	Audios (Please paste the sound cloud link etc.)	:
Other Documents (Max 4 Collaterals, PPT, Report or other documentation)	:	Full Name of Awardee (As it should appear in the citation and trophy, if awarded)

Part - IV Entrant Details

Name	:	Designation	:
Organisation	:	Address	:
Gender	:	City	:
State	:	Country	:
PIN Code	:	Mobile	:
Phone	:	Fax	:
Email	:	Website	:

Entry Type	Date	Fee
Early Bird	Thursday, September 15, 2016	FREE
Final Call For Entry	Saturday, October 15, 2016	INR 1000
GALA AWARD NITE: Friday, February 17, 2017

I hereby confirm that the particulars provided above are true to the best of my knowledge. I am also the authorised representative/ person to apply for this award.