Nomination Form

1.  I/We, am/are hereby nominating for the recognitions indicated below:

List of Recognitions{Please tick one}

Citizen ExtraordinaireCorporate CitizenOutstanding NGOPride of WorkmanshipYouth IconEnvironment ConservationStart Up Success

Declaration


I/We hereby declare the following:

1) In our knowledge and belief, the nominee indicated above is worthy of the recognition.

2) The nominee has been carrying out exemplary work in their vocation.

3) In our knowledge and belief, the nominee is of a good repute and standing, and there are no cases or proceedings against the nominee which would be a hindrance for Rotary Club of Bangalore to confer the recognition on the nominee.

4) I/We have informed the nominee of our intent to consider them for the recognition. The nominee has agreed and is willing to provide the information as required in Part B (Application Form/Data Information Sheet) to help RCB evaluate the application.

5) RCB can contact the nominee as per following details:

Name:

Email:

Mobile #: