Instructions :
Ř
This nomination form
must be completed in English
Ř
The nominee is required to sign this form under
Truth of Information Release.
Ř
Please
complete in Block capitals using typescript or black ink suitable for
photocopying and ensure that you complete all sections before signing and
dating the form on the back page.
Ř
Official
original Application form is required for processing although you may fax or
e-mail your completed form.
Ř
All
questions must be answered accurately and in full. Incorrect or misleading
statements can results in the denial of your application, or if you are
admitted, your dismissal from Ansted University and its Foundation.
Ř
This
nomination form should be completed and returned to us by mail only on or
before 31st July 2004 to :
The
Department of Ansted Social Responsibility International Award,
Ansted
University Asia Regional Service Center, P.O. Box 1067, 10840 Penang. Malaysia
Email:
bnhaw@tm.net.my Fax:+6-04-828 4911 or 6-04-399 3739 Tel:+6-012-470 5688
The
information provided on this Nomination Form will be strictly confidential and
will be used only by The Department of Ansted Social Responsibility, Ansted
University and the independent panel of judges in the selection process.
To be eligible, the nominee must be 18 years and
above. Any citizenship is acceptable.
Family/Surname/Last
name: __________________ Given name: ___________________________________
Title: __________________
Name
of Organisation/Institution: _______________________________________
Nature
of business activities:
_________________________________________________________________
Position
held/ Job Title: _________________________________
Department:__________________________
Mailing
address:
___________________________________________________________________________
Nationality:_____________________
Sex: __________ Age:_________ Marital Status: ___________________
Please
use full international telephone and fax numbers providing country code, area
code, and number:
Telephone
(office): _____________________ (Home): ___________________(Mobile) :
__________________
Fax(Office): __________________________ Email(s):
_____________________________________________
WWW
address (organisation):
____________________________(personal):____________________________
Indicate
the categories for which the nominee would like to be considered.
1.
Business, economic and/or entrepreneurial accomplishment in relation to
the social responsibility aspect.
2.
Political, legal and governmental affairs in relation to the social
responsibility aspect.
3.
Academic leadership and accomplishment in relation to the social
responsibility aspect.
4.
Cultural achievement in relation to the social responsibility aspect.
5.
Moral and religious leadership in relation to the social responsibility
aspect.
6.
Contribution to children, world peace and/or human rights in relation to
the social responsibility aspect.
7.
Humanitarian and voluntary service in relation to the social
responsibility aspect.
8.
Scientific and technological development in relation to the social
responsibility aspect.
9.
Personal development and accomplishment in relation to the social
responsibility aspect.
10.
Medical
innovation in relation to the social responsibility aspect.
For
corporate nominee, what is the legal structure of the nominee’s business?
(
) Sole Proprietor (
) Partnership (
) Private Limited Company (
) Public Listed Company
Has
the nominee or the nominees business been subject to an investigation by a
government body or a criminal charge in the past? (
) Yes (
) No
Final
determination of the number of categories and awards to be presented will de
decided by the judging panel based on the role a nominee has been contributed to
the society at large, quantity and quality of the completed nomination forms
received by the deadline.
To
the best of my knowledge, the information provided herein is true and complete.
All information provided in the application form remains confidential to Ansted
University Asian Regional Service Center and the Award judges, I understand that
the information I provided on this nomination form will be used by Ansted
University Foundation and the independent judging panel in selecting award
recipients and I consent the use of such information for such purpose. I further
consent to my name, photographs, video recordings, and audio recordings od me
from whatever source to be used for promotional purposes throughout the Ansted
Group Company’s name, photographs, video recordings, and audio recordings of
me from whatever source to be used for promotional purposes throughout the
Ansted Social Responsibility International Awards. I agree that no compensation
shall be payable to me or my company for such usage. I agree to use the name
“Ansted” when referring to the award and to otherwise co-operate with Ansted
Social Responsibility International Awards in promoting the Award.
Declaration
& Agreement
·
I
declare that to the best of my knowledge the information supplied above and
enclosed in support of my application is correct and complete.
·
I
acknowledge that the provision of incomplete or misleading information may lead
to the revocation of any decision made in respect of this application.
·
I
authorise Ansted University Foundation Board to obtain where appropriate and
verify any information with the relevant authority.
·
I
hereby declare that I agree to the selection rules and I am willing to be
proposed as a nominee for the Award and I will attend the awards presentation.
If I am unable to attend the award ceremony I have no objection to give this
award opportunity to other qualified candidate.
In
the event that I am an award recipient, I understand that Ansted reserves the
right to invalidate the award given to me should there be any significant
misconduct or non-legal acts on my part.
Nominee’s
Signature:_______________________________Date:_________________
Nominator’s
or Referee’s Signature:_______________________________Date:_________________
Please
provide all available documentation. All documents must be in English or
translated to English.
Complete
the Official Nomination form
Attached
2 passport size photograph with your name written on the back
Attach
copies of any and all diplomas, awards, certificates, transcripts,
recommendation letters received and professional
or special training
Business
or call card
An
executive summary of appropriately 200 words on the nominee to be used for
media and promotional purposes;
should include an overview of the nominee and should focus on his/her growth
as a Responsible Social contributor and reserves the right to make
amendments as it deems necessary.
Please
signed and dated the form
Referee
form
Office use only :
Category
of Application : _________________________ Status of Application
: _________________________
Date
Received : ________________ Received by : ___________________Remark :
_________________
Assessor’s
Comments/Recommendations :
_________________________________________________________________________________
Assessor’s
Signature : ____________________________________Date : ______________________
Please
write on a separate sheet of paper your reasons why the award should be given.
Your
answers should include a brief response to as many of these questions as is
relevant:
1.
List business, civic and community organizations to which the nominee
belongs and define the extent of involvement. Include specific tasks of
community involvement that illustrate how the nominee demonstrated vision and
creativity in a socially beneficial way.
2.
Can you tell us Social Responsibility build on what (example: kindness,
endurance, passion, vision, courage, etc.?
3.
Can you tell us something about yourself and your background? Describe
the nominee’s background, including skills, experience, major accomplishments
etc.
4.
Describe the history of the company founded by the nominee and under the
leadership of the nominee. Include source of the idea for the original strategy,
the degree of difficulty in launching the company social responsibility
contribution, other significant obstacles that were overcome, and any other
pertinent information. Describe how the idea was managed to implement. Attach
promotional materials.
5.
Describe how the company or yourself, under the leadership of the
nominee, has created a social responsibility model that demonstrates a clear and
sustained capacity for creativity and innovation in the development and
implementation of social responsibility activity and is unique or innovative in
its relations with customers, employees and society at large.
6.
Describe the nominee’s vision for the implementation of social
responsibility activity. Provide information about the social responsibility
task’s current stage of development, the plans for future growth and how the
nominee will achieve his/her vision.
7.
Provide information, which would help the judges understand the
challenges, problems and scope of the nominee’s area of activity.
8.
Describe the nominee’s exceptional achievements or contributions in the
Social Responsibility task and its activity in the chosen field.
9.
Please list and supply evidence of any commendations, statements of
authorities, honours and awards, which attest to and substantiate the
nominee’s achievements or contributions.
10.
Summarize the nominee’s most outstanding humanitarian effort, how the
nominee exemplifies the importance of Individuals and Corporate Social
Responsibility.
11.
Summarise the reason why you (the nominator) believe that your nominee
should be selected as one of the Ansted Social Responsibility International
Award in the relevant category of award created by Ansted University Foundation
Board.
12.
Describe the Social Responsibility management team in your company and
the nominee’s relationship with them. Provide specific examples of management
successes which have contributed to the growth of the business after
implementing the social responsibility project within and/or outside of the
company.
13.
Describe the people’s initiatives created and sponsored by the nominee
in the company. Address how the company’s environment and culture nurtures
these initiatives, including examples of recognition and reward provide specific
examples of how these initiatives and the nominee’s values serve to empower
and retain the work force after the company involving in the social
responsibility activity.
14.
What experience or encounter in your life has influenced you the most, be
a Social Responsible person?
15.
What are the main highlights of your personal and professional life in
related to Social Responsibility issue?
16.
Which of there are you the most proud of in the area of performing social
responsibility tasks?
17.
What is your idea and definition of success in life towards the Social
Responsibility scope?
18.
How can you achieve this success?
19.
Who do you think are the great talents in your field that he/she had
contributed the most in Social Responsibility aspect?
20.
What person, living or dead, do you most admire and why? How has that
person influenced your perspective of life to become more active and involve
actively in performing Social Responsibility duty?
21.
What person, living or dead, do you identify with most contribution to
this task?
22.
What failures, if any, have you encountered so far, and what are some of
the lessons you have learned from them?
23.
What do you regret most about your career and life when you did not play
your social responsible task?
24.
What is the single thing you have learned in the past year that is most
meaningful to you without doing social responsibility task?
25.
Do you have a personal motto? What is it? Is that also included social
responsibility task?
26.
If you can change one thing in your life, what would it be?
27.
How do you improve yourself in your own personal development and continue
to stay motivated constantly?
28.
What would you advise others who desire to excel in your discipline or at
least, generally, in their work?
29.
What do you like best and most about your work in the area of Social
Responsibility?
30.
What is your regular day like? How regular you think of ways to improve
social and society problem?
31.
What do you hope to do and achieve one year from now?
32.
Any advice for Ansted University students and alumni members?
33.
How do you think your discovery and message has helped mankind in the
world today?
34.
Please provide a brief, but specific, description of the social
responsibility tasks that you have been doing or you have done in the past,
which bring benefit to society. (This will be used in media and print materials)
35.
If you
are nominating yourself please respond to the following questions:
Please give us a brief
resume of your academic/professional contributions in the last 10 years or so.
What are your broad
areas of academic/professional interest?
How
have you utilized them for the benefit of society?
What
in your opinion is corporate social responsibility?
Please
provide us with 3 names of responsible individuals along with their complete
addresses [phone, fax, email etc], which will serve as our reference, for
future communication.
The
following few questions are applicable to Nominator:
Family/Surname/Last
name: __________________ Given name: _____________________________________
Title: __________________
Name
of Organisation/Institution: _______________________________________
Nature
of business activities:
_________________________________________________________________
Position
held/ Job Title: _________________________________
Department:__________________________
Mailing
address:
___________________________________________________________________________
Nationality:_____________________
Sex: __________ Age:_________ Marital Status: ___________________
Please
use full international telephone and fax numbers providing country code, area
code, and number:
Telephone
(office): _____________________ (Home): ___________________(Mobile) :
__________________ Fax(Office): __________________________ Email(s):
_____________________________________________
WWW
address (organisation):
____________________________(personal):____________________________
In what
academic/business field does the nominee distinguish himself/herself?
How long have you known
the nominee?
In what way has the
nominee contributed substantively to corporate life?
What are the 'special'
reasons in your opinion, for which the nominee deserves the award?
We are not only looking
for individual excellence but community service more importantly.