:: Un MDG Awards:Nominations

MDG AWARDS NOMINATION FORM

IMPORTANT INFORMATION:

1. The Nomination Form must be completed once begun. The information can not be saved and then returned to at a later time. Therefore, please review the Nomination Form before beginning your registration.

2. To cover the cost of processing your nomination and charges incurred during the selection process, there is a nominal charge of $10 per nomination. When you submit your Nomination Form you will be requested to make the payment.

1. Contact Information

You may nominate your own organization, another organization, an individual, or yourself

Full Name*

Phone*

Fax

Title

Email*

Verify Email*

Website URL Address

Applicant Name*

Applicant City

Applicant Address*

Applicant State

Applicant Country*

Applicant Postal Code

Applicant email*

Applicant Phone*

Applicant Fax

3. Identification of the initiative (Primary MDG )

Application category (correspondent to one of the eight MDGs or multiple MDGs)*
PLEASE CHECK BOX

MDG # 1. Eradicate extreme poverty and hunger.

MDG # 2. Achieve universal primary education.

MDG # 3. Promote gender equality and empower women.

MDG # 4. Reduce child mortality.

MDG # 5. Improve maternal health.

MDG # 6. Combat HIV/AIDS malaria and other diseases

MDG # 7. Ensure environmental sustainability.

MDG # 8. Develop a global partnership for development.

OTHER: Project works to attain more than one MDG.

4. Project Description

Does the initiative involve the community it aims to serve? NoYes

Date on which implementation of the initiative began:--

Place where the initiative is being carried out

About how many people are affected by this initiative?

Is the initiative still being implemented:NoYes

In 1000 words or less, please answer the following:

Describe the initiative (goals, activities, main results).
Explain the rationale behind the initiative. Quantify the need.
How has this initiative worked to achieve this MDG? If possible, please quantify the impact of this work.
Is this initiative innovative? If yes, In what ways?
Are partnerships involved in this initiative? If yes, who are the partners?
What is the sustainability of the initiative? What are plans for the future?
Sources of funding and approximate annual budget.
How are you determining the success of the initiative? Has an evaluation taken place, and is it available?
Other information – Please add anything of importance you wish to convey about the initiative. For example, has it been able to impact policy at the local, regional or national level?

5. Others familiar with your work

Please give the names of at least two individuals outside your organization who are familiar with the work of the applicant. They may be contacted to ask for supporting information.

Name

Title

Organization

Postal Address

City, State

Zip Code

Country

Fax

Name

Title

Organization

Postal Address

City, State

Zip Code

Country

Fax

e-mail signup: