Indian Institute of ManagementPrabandh Nagar, IIM Road, Lucknow - 226 013

Tel.: 91-0522-2734111-20 Fax: 91-0522-2734005 Email: diroffice@iiml.ac.in

In association with:

N o m i n a t i o n F o r m

• Please read the criteria for selection carefully before filling this form.• Please choose one category per form.• For more than one nomination please use photocopies of the form.

I wish to nominate (Mr./Mrs./Ms.)

For demonstrating excellence & leadership in the field of:(Please choose one category per nomination form)

If possible, please state how this particular individual has excelled with fundamental leadership quality in his field to accomplishthe larger goal of society and nation building.

Age/D.O.B. : Present Assignment

Address : City :

Organisation : Phone No.: Email ID :

Your Name : Address :

Signature : Date : Email ID : Tel. :

CRITERIA FOR SELECTION

Nominee Should: • Be a resident of India (NRI / Foreigners excluded) • Have fundamental Leadership values • Have shown exemplaryperformance and contributed towards development in his/her field for the larger goal of Society and Nation building • Have shown excellencedespite challenges • Have high personal values and ethics • Should not be active in Politics, Films and Sports• The nominee for the Young Leader category should be a person around 45 years of age, who has shown exemplary performance, recognised in the country, with potential to reach the pinnacle in the years to come.

For more on the awards, you may visit : or www.lpsiimlawards.in www.iiml.ac.in

NOMINATIONS SHOULD REACH US BY 25th NOVEMBER, 2017

Science & TechnologyBusiness

Leader

Young Leader(around 45 years)

Leader

Young Leader(around 45 years)

Leader

Young Leader(around 45 years)

Community Service & Social Upliftment

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