Nomination Form


Vigil India Movement – Bangalore

M.A. THOMAS NATIONAL HUMAN RIGHTS AWARD 2016

Nomination Form

Nominee:

Name


Sex

Age / Date of Birth

Address





Telephone

Email

Please state the organization (if any) to which the nominee is affiliated and the nominee’s position in the organization
Name of the Organization

Address





Web address

Email


Reasons for nomination (to be written in a separate sheet)

Ø  Please justify your nomination by describing clearly the nominee’s contribution towards the protection and promotion of human rights in India. Enumerate the activities, achievements and impact on society or state policy.

Ø  Please include a brief resume of the nominee.

Ø  Please attach any reference material in connection with the above that you may have.

Nominator

Name


Profession

Address




Telephone

Email


For Office Use Only






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