1. Nomination Form
Sankalp Social Enterprise
Awards 2013
Submission Deadline: January 20, 2013
Email: sankalpforum@intellecap.net
Website: www.sankalpforum.com

2. Instructions for Participation
1. As an applicant/nominee to the Sankalp Social Enterprise Awards 2013 your enterprise should have
an operational focus on India.
2. Only operational enterprise registered as a for-profit business are eligible to apply for the Sankalp
Social Enterprise Awards
3. The enterprise should have been in operation for a minimum of six months before applying.
4. Your enterprise must be catering to one of the following 5 high impact sector:
i. Agriculture, Food and Rural Business
ii. Clean Energy/Clean Technology
iii. Education and Vocational Training
iv. Health, Water and Sanitation
v. Technology for Development
5. This application is only for enterprises with a business operation focus in India. Completed
nominations must be submitted at sankalpforum@intellecap.com
Note: Last date of submission January 20, 2013. Late entries will not be accepted.
Section 1 – Basic Information
Full Name of the Company
Full Name of the Founder (s) Promoter / Co-Promoters
Operating since Month & Year
Sector of Operation Agriculture, Food and Rural Business, Clean Energy/Clean Technology, Basic
(choose only 1) Service Provision and Delivery (Health, Water, Sanitation, Education)
Headquarter City
State
Geographic Areas of Operation All India
(Mention the states of operation)
Email
Mobile Number
Landline Number
Website
Section 2 – Understanding your Enterprise
Date of Registration/ DD/MM/YYYY format
Incorporation
Legal Status Sole Proprietorship, Partnership Firm, Private Ltd Company, Producer
(Choose one) Company with Pvt Ltd Subsidiary
What is the vision and mission
of your company?

3. Have you received any
incubation support? Please
mention details of the
incubator, support received
and duration.
Section 3 – Opportunity and Market
What is the business
opportunity that your company
addresses?
Outline the size of the market People
opportunity Monetary value
Reach
Impact
Who are your primary target Please elaborate on numbers, type, location, monetary value, etc.
audience/ client/ customer?
Section 4 – Enterprise Details
Provide details on the primary product/service that contributes to a majority of your company’s revenue.
(maximum 3 products)
Revenue Your position in the
Product Name Contribution (%) Description of product Top 3 Players market
Product 1
Product 2
Product 3
How do you access/reach out to
customers? What are your
distribution/delivery channels –
how it operates?
Are there any new products/
solutions that you are looking to
launch in the next 2 years?
Please describe
If your product is technology-
driven please explain your
technology or IP.

4. Section 5 – Competition
Who are the top 3 players and
what is their share? What is your
current market share in
comparison?
What is your value proposition in Elaborate with examples on cost benefit, if your product is addressing a
comparison with other players in specific customer pain point, unique technology, etc
the market?
Section 6 – Product Innovation
Please describe your
product/service innovation.
Elaborate on how it improves
your enterprise’s efficiency
What is the impact of your Elaborate with examples on cost benefit, if your product is addressing a
product/service innovation? specific customer pain point, unique technology, etc
Elaborate on its implications in
your scaling up strategies.
Section 7 – Team
Please mention details about the Leadership Team (Limit to 4 critical positions)
Full Name
Current Focus/ Area of
Responsibility
Title
No. of years’ experience in sector
Previous position 1
Previous position 2
Academic qualifications
Recognitions Awards
Do you have a Board of
Directors/ Board of Advisors? If
yes, please provide details on
their role and profile.

5. Current employee strength Total Employees
Projected employee strength in 3 Total Employees
years
Section 8 – Social Impact
What is the social impact that Note for e.g. these could be some of the ways you can create impact
your product/service has
created? You source from disadvantaged/marginalized sections of society? OR
You sell an essential product or service to marginalized/disadvantaged
sections? OR
You have a product that enables better delivery of an essential service
to a section of the society OR
You have a product/service that can benefit the environment/bring
about energy efficiency? In short any solution that has a substantial
positive impact on society!
Section 9 – Financial Model
Indicate your current funding Debt: Amount and Sources
streams Equity: Amount and Sources
Founders Stake: Amount and Sources
How much investment are you INR Lakhs
seeking for your enterprise?
Show us what you have accomplished to date, financially
Particulars INR Lakhs INR Lakhs INR Lakhs
FY 2009-2010 FY 2010-2011 FY 2011-2012
Total Income
Total Expenses
EBITDA
Profit After Tax
If you have been operating for
less than a year, what has been
your capital burn out ratio as
compared to the revenue earned?
What are the key milestones you
aim to achieve with the capital
infusion?

6. Identify 3 strategies that will help No of additional centers, distribution channels, assets, geographic
achieve your growth targets in expansion etc
the next 18 months.
What is your revenue estimation for next 3 years? (Projections)
Particulars INR Lakhs INR Lakhs INR Lakhs
FY 2012-2013 FY 2013-2014 FY 2014-2015
Total Income
Total Expenses
EBITDA
Profit After Tax
Please tell us what are the other
awards or recognitions your
enterprise has received?
Lastly, why should your
enterprise win the Sankalp
Award?
THANK YOU!
Contact:
Email: kanika.kumar@intellecap.com Call: +91.22.40359212
Website: http://www.sankalpforum.com/ Blog: http://blog.sankalpforum.com/
Terms and Conditions*
1. The Sankalp Social Enterprise Award organizing committee does not take any responsibility for disputes related to awards
given to entrepreneurs.
2. Winning the ‘Sankalp Social Enterprise Award does not guarantee an investment to your enterprise
3. This recognition is not a reflection of the quality/success of your enterprise and has been made by the sole discretion of
the independent jury
4. The decision of the Sankalp Social Enterprise Award Jury with respect to selection of winners will be final and binding
5. All information disclosed via the nomination form will be kept confidential