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Application form for the

(Social Entrepreneur of the year award, individual Category)

This form must be completed and sent back to the World Charity alliance by post or e-mail*

Date: dd/mm/yy
Registration Number (As provided by World Charity Alliance):
Personal Information
Q1. Surname/family name
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Q2. First name
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Q3. Middle name(s)
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Q4. Date of birth
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Q5. Citizenship
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(Note: You must provide proof of birth and proof of citizenship whenever you asked it.)
Q6. Gender
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Q7. Ethnicity (Optional)
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Q8. Postal address
(The address to where WCA can send you correspondence)

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Q10. Contact details
(The numbers and email address where WCA can contact you)

Phone (Home)

...................................................

Fax

...................................................

Email

...................................................

Mobile

...................................................

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Q11. Are you currently in receipt of a benefit from employment, or any other financial assistance?

Yes

No

Please write the source of the income.............................................

Employment Detail (If any)

Start Date

Finish Date

Employers Name

Position Held

Reason for Leaving

Educational Qualifications
List all colleges and universities attended in chronological order.
Name and Location of Educational Institution

Dates
Attended

Major Field of
study

Degree/Qualification

Year
Awarded

Academic honours, scholarships, fellowships, or any other achievements:

Supporting Information
Q12. Give the name of project which you have implemented.
......................................................................................................................
......................................................................................................................

GPA/Mark

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Q13. Outline why you believe that intervention made by you/your team was need based.
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Q14. Type of activities, you have done during project implementation.

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Q15. What were the objective and working methods of the project?
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Q16. Outputs (results achieved):
......................................................................................................................
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Q17.In which way Local authorities were involved or can benefit of your project?
......................................................................................................................
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NOTE: Please enclose Your Curriculum Vitae

Falsifying or withholding information in completing this application constitutes grounds for immediate withdrawal
of your application from further consideration, or cancellation of your admission or registration. By signing below,
you certify that all information you have given is complete and correct.

Signature

Date