A S I A A N D T H E PAC I F I C E N T R E P R E N E U R S H I P
AWA R D S 2 0 1 6 U N I T E D A R A B E M I R AT E S
O F F I C I A L N O M I N AT I O N F O R M
Category (please tick one - additional category should be submitted in different form)
Most Promising Category
Outstanding Category
Industry (please tick one)
Agriculture
Education & Training
Automotive
Electrical & Electronics
Chemical and Plastics
Consumer Goods
Construction, Property &
Building Materials
Healthcare, Pharmaceutical &
Biotechnology
Financial Services
Food & Beverage
Furniture & Woodbased Manufacturing
Hospitality, Food Service & Tourism
Industrial &Commercial Products
Media & Entertainment
Oil & Gas, Mining & Energy
Personal Services
Please complete all sections in CAPITAL letters
Professional & Business Services
Retail
Telecommunications & ICT
Trading & Wholesaling
Transportation & Logistics
Others (Please Specify)
1. 0 CO RPORAT E I NF O R M AT I O N
Company Name
Business Registration Number
Legal structure of the company:
Private Limited
Date of Incorporation
Public Listed
Government Owned/Linked
Primary Address
Postal Code Country
Tel. No. Fax No. Authorised Capital Paid-up Capital No. of Employees
Liaison Person
Total Annual Payroll
(in local currency)
Designation Email D.O.B (dd/mm/yyyy)
Mobile No. Email ID / Passport No. Nationality
Mobile No. 2.0 N OM I N EE I N F O R M AT I O N
Nominee’s Name
Designation
Is the company founded by you?
YES
Years in Industry NO
Years in Company Years in Present Position Highest Academic
Qualification
Professional Certification / Accreditation (if any) Has the nominee or nominee’s organization been investigated for any criminal / civil offence in the past 5 years?
Yes
No
3. 0 FI N A N C I AL I N F O R M AT I O N
Investment (in local currency) spent on the following functions for the last financial year. Documentary proof may be requested.
Financial Year:
From
Research and Development
Corporate Social Responsibility
Marketing and Branding
Education and Training
IT Infrastructure and Software Total Sales
To
4.0 SUPPORT I N G DOC U M E NTAT I O N
Please attach the following documentation with your Nomination Form. Failure to provide complete documentary support may render your
nomination void or adversely affects your chances of winning.
Latest Audited Accounts - Audited accounts must reach the organizer by the stipulated deadline.
(unaudited management accounts may be submitted, but subject to audit by appointed auditors)
Additional supporting documents which you feel may support your nomination can be submitted to us (Optional)
5 .0 DEC L ARAT I ON
I hereby declare that 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 (except normal business relationship, if any). I further declare that I have not
attempted and will not attempt in any manner, monetary or otherwise, to influence the decisions of the Organizers and/or the judges.
Nominee’s Signature:
Name Date
IMPORTANT! Please include USD150 with every Nomination Form submitted, payable to the following:
Bank
: OCBC Bank (Malaysia) Berhad
Name of Account : Business Media International Sdn Bhd
Account Number : 707-114327-8
Address : 89, 91 & 93, Jalan SS 21/60. Damansara Utama, 47400, Petaling Jaya
Contact Number : 1300 88 7000
Swift Code : OCBCMYKL
Completed nomination form and attachments should be sealed and sent to the following address:
Asia and The Pacific Entrepreneurship Awards 2016 - UAE
Unit 709A, Level 6 Kelana Parkview Tower, Jalan SS 6/2, Kelana Jaya, 47301, Petaling Jaya, Selangor, Malaysia
Nomination Hotline: +603 7803 0312
Fax Line
: +603 7803 0150
Email inquiries
: emirates@enterpriseasia.org
6. 0 O F F I C I A L USE O NL Y
Date Received
CODE
Quantitative Audit Qualitative Appraisal