Nomination Form

Nomination closing date: Monday, 31st August 2009. When completed please return to:
future100@fyse.org. Please name your file: “nominee name _ country”.

Contact Information Nominee:

First name: Last name:

Telephone: Email:
Address: Country:
Occupation: Date of Birth:
Highest academic qualification high school bachelor master postgraduate
Previous awards:

Business/ NGO/ project information:

Name of the Business/ NGO/ project:

Address:
Website:
Month/Year of establishment: Business registration number:
No. of fulltime employees: No. of part-time employees: No. of volunteers:
Is the Business/ NGO/ project founded by you? Yes No
Did your Business/ NGO/ project start operations at least 12 month prior your AP Future100 application?
Yes No

1. Please describe your business/ NGO/ project. [main objective(s), idea(s), concept(s),
impact]
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Nominee name:

2. Please provide an overview of your products and services.

3. How is this business/ project innovative?

4. What do you want to achieve with your business/ NGO/ project?

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Nominee name:

5. Please elaborate why you started your own venture. How did you come up with the idea?
What inspired you?

6. What challenges did you have to overcome? How did you succeed?

7. What has been your and your ventures biggest success and your biggest failure been so
far?
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Nominee name:

8. Where do you want to take your venture? Where do you see your business in 10 years?

Nominee Declaration

I hereby declare that I read the terms and conditions of the Future100 and agree to all terms and
conditions with my signature below. I further declare than the information submitted herein and as
supporting documentation are to my best knowledge, true and verifiable. I understand and agree that
should any of the information submitted herein and as supporting documentation are found to be
factually incorrect or are designed to mislead the judges, my nomination will be voided, and if I’ve been
declared a winner, my award will be rescinded. I declare that I am not related to any staff of the
Organizers or to any judges appointed by the Organizers. I further declare that I have not attempted and
will not attempt in any manner to influence the decisions of the Organizers and/or the judges.

Name: Date and Place: Signature Nominee:

Supporting documents:
1. 2 recommendation letters about the Entrepreneur
Organizational Marketing Material incl. brochures/ website screenshots, flyers etc.
3. soft copy of passport/ national ID card
4. CV of entrepreneur incl. copies of any awards achieved

How did you get to know about Future100?