I.

BASIC INFORMATION OF THE NOMINEE

NAME OF NOMINEE( FIRST, MIDDLE INITIAL, SURNAME)

COMPLETE CURRENT ADDRESS

DATE OF BIRTH EMAIL ADDRESS
SEX MALE FEMALE (MONTH/DATE/YEAR)
CONTACT NO.

DISABLITY PWD ID NUMBER

II. BACKGROUND OF THE NOMINEE
SOURCE OF INCOME
(may select more than one)
EMPLOYMENT
NAME OF CURRENT EMPLOYER/COMPANY:
DESIGNATION:
BUSINESS (Please specify nominees business/es):

OTHERS (Please specify):

ORGANIZATIONAL/INSTITUTIONAL AFFILIATION (Use a separate sheet if necessary)

NAME OF ORGAIZATION POSITION/ROLE TERM/SERVICE PERIOD

II. PWD STORY (Use a separate sheet if necessary)

MOST SIGNIFICANT ACCOMPLISHMENT/S AS A WOMEN WITH DISABILITY

III. ACTIVITIES
TITLE AND DESCRIPTION OF ACTIVITY
(Please identify maximum of five (5) outstanding volunteering AREA/ SITE WHERE SPECIFIC ROLE/
activities of the nominee. Period covered: last three(3) years for MODE
DATE AND DURATION NO. OF TYPE OF THE VOLUNTEERING TASK PERFORMED
the youth category and at least five (5) years for the adult (Onsite, Online, or
(Hours covered) BENEFICIARIES BENEFICIARIES ACTIVITY WAS (Head, Support,
category) Hybrid)
CONDUCTED Participant)

IMPACT OF ACTIVITIES (Use a separate sheet if necessary)

TITLE OF ACTIVITY ATTENDED IMPACT
1

4
5

PLAN TO SUSTAIN THE WORKS FOR THE PWD SECTOR

ADDITIONAL INFORMATION ON DIFFERENT ACTIVITIES (Use a separate sheet if necessary)