Nomination form - ICIMOD Mountain Prize 2021

Nomination form – ICIMOD Mountain Prize 2021

The deadline for the submission of nomination is 30 September 2021. Only selected candidates will be informed via email . Please refer to this page for further information.

Asterisk(*) indicates required field.

Individual nomination formOrganizational/Company nomination form

1. Nominator’s (i.e., your) information

Your full name

Title*

First name*

Middle name

Last name*

Your organization/company*

Your job title*

City and country in which you live

City*

Country*

Your contact details (landline/phone number, mobile/cell number, email address, fax number)

Phone number*

Mobile number*

Email address*

Fax number

Your relationship to the nominee*

[group group-individual]

2. Individual nominee information

Your nominee’s full name

Title*

First name*

Middle name

Last name*

Name of the organization/company your nominee works for (or if self-employed, please indicate)*

Your nominee’s job title*

City and country in which your nominee currently resides/works

City*

Country*

Your nominee’s contact details (phone number and email address)

Phone number*

Email address*

[/group]
[group group-organization]

2. Organizational/company nominee information

Full name of the organization or company you want to nominate*

Homepage (URL) of the nominated organization or company

Full name of the Head of the organization or company (please include his/her proper job title)

Full name*

Job title*

Email address of the head of the organization/company*

City and country in which the nominated organization or company is based

City*

Country*

Contact details of the nominated organization or company (landline/phone number, email address, fax number)

Phone number*

Email address*

Fax number

[/group]

3. Nomination form

SECTION A. Thematic areas of work

List the thematic areas in which your nominee has made a significant impact*

SECTION B. Setting the context

Provide an overview of your nominee’s outstanding pandemic-response work. What were the expected results of the work, and where in the Hindu Kush Himalayan region was it carried out? (e.g., was it an individual effort, or did the nominee work as a part of a larger team? If it was a team effort, who were the key partners?) [300 words]*

SECTION C. Resilience building

How did the nominee’s work enhance the resilience of the target community (e.g., did it improve socio-economic conditions, access to goods or information, etc.)? [400 words]*

SECTION D. Transformative change

How has the nominee’s work contributed to transformative change on the ground in terms of social, economic and environmental factors (e.g., how many households or people benefitted from the work – directly and indirectly– and how; did it lead to innovation or contribute to green recovery)? [400 words]*

SECTION E. Gender and social inclusivity

How does the nominee’s work address gender or other social inclusion issues? [400 words]*

SECTION F. Prize worthiness

Why does your nominee deserve to win the ICIMOD Mountain Prize? [100 words]*

SECTION G. Supporting documentation

Compile into one document and upload here electronic copies of any supporting documents that provide evidence of your nominee’s outstanding work and achievements. (Maximum file size 5Mb)

Choose a file

Does the head of your nominated organization/company know that you have nominated his or her organization/company for the ICIMOD Mountain Prize? Yes or No? (If you chose “No”, please inform him/her accordingly)*

YesNoNot applicable

I confirm that the above information is accurate and complete to the best of my knowledge.