2016 JCI Mauritius TOYP Application Form

Transcription

1 2016 JCI Mauritius TOYP Application Form The JCI Mauritius Outstanding Young Person Award (TOYP) serves to formally recognize young people who excel in their chosen fields and create positive change. By recognizing these young people, JCI raises the status of socially responsible leaders in this world. The honorees motivate their peers to seek excellence and serve others. Their stories of discovery, determination and ingenuity inspire young people to be better leaders and create better societies. How to apply Download, complete and submit the signed application form below in its entirety no later than May 13, 2016 on All fields are required and may be filled in either English or French. Applications will not be accepted after the deadline. Eligibility 1) Nominees must be between the ages of 18 and 40. Nominees born before January 1, 1976 or after December 31, 1997 are not eligible for JCI TOYP. A copy of the National ID Card or Birth Certificate should be enclosed along with the application form. 2) The nominee should be a citizen of the Republic of Mauritius 3) The nominee must be a resident of the Republic of Mauritius and be present in Mauritius during the judging process and for the Awards ceremony. 4) The nominee should not be a current member of the JCI Mauritius board at the International, National or Local level. 5) The nominee/ nominator must attest to all facts contained in the form and grant permission for publication of these facts. The nominee may be required to attend the JCI TOYP Awards Ceremony in Quebec, Canada, if selected as a 2016 Honoree. 6) All information must be contained on the application form. Video clips, Scrapbooks, audiotapes, etc. are not used in the judging process. However, if a candidate is selected as one of the ten international honorees, these items will be requested by JCI World Headquarters. Application Documents A good quality, 4" x 6" (10 cm x 15 cm) black-and-white, head-and-shoulders photograph must be submitted along with the official nomination form. This file must be in JPG Format and cannot be greater than 2MB of size. National Identity Card or Birth Certificate: A copy of the ID/Birth Certificate should be attached along with the nomination form This file must be in JPG Format and cannot be greater than 2MB of size. Application Form: Application form must be signed by Nominee and Nominator Unsigned application form will be rejected.

2 Please Select Category: PART 1 - NOMINATION FORM Business, economic, and/or entrepreneurial accomplishment Political, legal, and/or governmental affairs Academic leadership and/or accomplishment Cultural achievement Moral and/or environmental leadership Contribution to children, world peace, and/or human rights Humanitarian and/or voluntary leadership Scientific and/or technological development Personal improvement and/or accomplishment Medical innovation Part 1A. Personal & Business Information (To be filled by nominee) NOMINEE S FIRST NAME:* (as it appears in I.D.) (*) Required Field NOMINEE S SECOND NAME:* (as it appears in I.D.) TITLE:* (Dr./Mr./Mrs./Ms./PHD,etc.) NAME TO APPEAR ON THE TROPHY:* (your name and any professional title (such as Doctor) EXACTLY as you wish it to appear on your trophy, in the video, and any other material produced for the 2016 TOYP Program in case the you will be selected as one of the honorees.) BIRTHDATE (DD/MM/YYYY):* HOME ADDRESS:* ADDRESS:* HOME TELEPHONE:* MOBILE NUMBER:* OCCUPATION OR PROFESSION:*

3 BUSINESS NAME (IF APPLICABLE): BUSINESS ADDRESS (IF APPLICABLE): BUSINESS TELEPHONE: ADDRESS: EDUCATION (DEGREES, ACADEMIC HONORS, ETC.):* CIVIC, FRATERNAL, ORGANIZATIONS AND AFFILIATIONS: PUBLISHED WORKS:

4 Part 1B. Nominee s Career information (to be filled by nominee) (*) Required Field Outline the career of the nominee, including background on the nominee s work or field of activity.* Provide information which will help the judges understand the challenges, problems, and scope of the nominee s area of activity. *

5 Describe the nominee s exceptional achievements or contributions in his/her chosen field * List public statements from authorities, honors, and awards received which affirm the nominee s achievements or contributions. *

6 Part 1C. To be filled by Nominator** Summarize the nominee s most outstanding efforts that exemplify the principle expressed in the following line of the JCI Creed: That service to humanity is the best work of life. * (*) Required Field Summarize within this space why you believe that the nominee should be selected as one of The Outstanding Young Persons of the World for 2016* Nominator** A nominator is a referee, someone who can bear testimony to your achievements (or one specific), other than yourself, it may be a member of your entourage or your family. A nominator can also be a well-established public figure or respected/renowned professional in his/her domain. It can be a superior or a co-worker. Alternatively a nominator maybe a member of JCI. If you have been awarded a recognition previously, the nominator may also be a jury person / organiser/ partner of the said competition

7 Part 2. DECLARATION The Following section should be completed by the Nominee I attest to all facts contained in my nomination form and give permission for the facts to be used for publication. In agreeing to accept a JCI TOYP Award, I understand that, barring extreme circumstances, I am required to be present from October 30, 2016 to November 4, 2016, for the JCI TOYP Ceremony and activities at the 2016 JCI World Congress in Quebec, Canada In the event that circumstances prevent my attendance, I must present the conditions to the President of JCI for a decision on the continued eligibility of my nomination. Signature of Nominee:. Date:.. Name of Nominee: The Following Section must be completed by the Nominator Name of Nominator: Telephone: Occupation/ Profession: If JCI Member, Name: Chapter:... Signature of Nominator:. Date:.. Name of Nominator: FOR OFFICE USE Name of National Organisation: Name of Organisation President: Signature of National President: Date: