NOMINATION FORM FOR WPDO HONORARY TITLES

(Please fill clearly in block letters and tick mark in appropriate box)

[ ]Mr. [ ]Rev. [ ]Pastor [ ]Bro. [ ]Evang. [ ]Prof. [ ]Dr. [ ]Miss. [ ]Mrs. [ ]Sis. [ ]Other

Full Name: ___________________________________________________________________________

Date of Birth: ____/_____/__________ Sex: Male [ ] Female [ ]

Father’s/Husband’s Name: _______________________________________________________ Please affix latest

passport size
photograph
Mailing Address: ___________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
__________________________________________________________________________________________________________________

City: ___________________ District: ___________________ State: ___________________________

Pin/Zip Code: ________________ Mobile No.: _______________________________

Email id: ___________________________________________

Qualification: _____________________________________

Experience: ___________ Years

Are you employed: [ ] Yes [ ] No

If employed, please provide name of the employer: _________________________________________________________

If employed, please provide the designation: ________________________________________________________________

Your Achievements (in any field), you may attach separate sheets:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Additional Declaration for Nomination of WPDO Honorary Title. Please inform Yes Or No in
the Following List:

a. Have you been charged under Criminal Law (YES/NO)

b. Are you employed in government service now (YES/NO)
c. Are you seeking this honor for political benefit (YES/NO)
d. Do you have any mental disorder (YES/NO)
e. Have you ever been engaged in human trafficking (YES/NO)
f. Have you ever been engaged in illegal money laundering (YES/NO)
g. Have you ever been engaged in abusing women (YES/NO)
h. Have you ever been engaged in abusing transgender (YES/NO)
i. Have you ever been engaged in abusing children (YES/NO)
j. Have you ever been engaged in abusing other colored people (YES/NO)
k. Have you ever been engaged in abusing other caste/community (YES/NO)
l. Are you supporting terrorism by any means (YES/NO)
m. Are you supporting and/or engaged in unlawful prostitution (YES/NO)
n. Have you ever been engaged violating religious freedom (YES/NO)
o. Have you ever been engaged in violating human rights (YES/NO)

NOMINATION FORM

Nominations are called by the World Peace & Diplomacy Organisation – WPDO for the WPDO
Honorary titles. This prestigious honor is given to an individual or an organization that has made a
significant contribution towards diminishing collective violence with increasing harmony that
enhances of human potential.

The nomination should provide an overall profile of the nominee and his /her specific contributions
towards peace-building. Summary documentation with referees is sufficient. Additional information
may be requested.

Dossier Instructions:
Self-attested documents to be attached along with the Application Form • Complete Profile • Photo ID
Proof • Address Proof

Referees

Referees must not be related to you. WPDO may contact them for a reference check.
Personal reference
Someone who has known you well in a social capacity for at least two years.

Name: ___________________________________________________
Address:_______________________________________________________________________________________________________
__________________________________________________________________________________________________________________
________________________________________________________________________________________________________
Occupation: _________________________________
Home Phone Number: _______________________ Work Phone Number: _______________________________
Mobile No: _________________________ Fax Number: ______________________________
Email Address: ______________________________________
How do they know you?: ____________________________________________________________________________

Professional reference
Someone who can comment on your professional skills; e.g. a tutor, a recent employer, or client if
self-employed

Name: ___________________________________________________
Address:_______________________________________________________________________________________________________
__________________________________________________________________________________________________________________
________________________________________________________________________________________________________
Occupation: _________________________________
Home Phone Number: _______________________ Work Phone Number: _______________________________
Mobile No: _________________________ Fax Number: ______________________________
Email Address: ______________________________________

Declaration:
I the undersigned hereby declare that the information provided by me in the application is true to the best of my knowledge
and belief. I have carefully read the WPDO Guidelines, other Rules and Regulations of WPDO, CIHF and & its partnering
affiliated bodies for application of WPDO Honorary Tiles and I understand that it is a not for profit body, hence it does not
come under purview of any government accreditation or approval. I agree to all terms & conditions for partnering affiliated
bodies & their constitutions and shall hereby keep them free from any legal liabilities or claims from my end whatsoever, I
shall always be bound to abide by the above mentioned terms & conditions, I also understand the use of such title in
personal profile should be strictly according to the governing law of that region. I also accept that WPDO will only proceed
with my application subject to check with the referees and the authorities which I mentioned in this application and I accept
that it is WPDO policy. I declare that I have never been convicted of a sexual offence, or dismisses from a post working with
children, the elderly or disable for malpractice. I am willing to undergo a police check if required.

Date: ____/____/_________ Signature: __________________________

Important Note: This application form is not an ordinary form, it is seeking higher degree in the society, so please fill the
application form carefully and attach required documents. If all the fields are not filled and the required documents are not
attached, the application will not be considered.