Nomination form for Social Entrepreneur Of The Year Award
Submission
directions
Complete this nomination form and return it to the organizing committee.
The EY Social Entrepreneur Of The YearTM nomination form for 2016 can be completed and submitted electronically to
[email protected]. The information included in this official nomination form will be considered confidential and will be
used only by the EY Entrepreneur Of The Year.
Definition
Social Entrepreneur is an individual who leads an organization, whether for-profit or not, to achieve large scale, systemic and
sustainable social change through innovation and entrepreneurial approach to social, economic and environmental problems.
Criteria
Checklist
Nominee
Please print or type.
(If more than one nominee,
attach sheet with their
information)
Please write your name and
company exactly as you want
it to appear on press release,
trophies, etc.
The information below should be filled by a founder/owner of the organization, ideally the founder, to be considered for the
Social Entrepreneur Of The Year Award. In order to be eligible, your organization has to be based in Indonesia.
In order to assess your candidacy for the Social Entrepreneur Of The Year award, we ask you to provide us with the following
documents (mandatory):
Completed and signed nomination form.
Copy of your Curriculum Vitae or resume.
The most recent evaluation report on your organization, preferably conducted by a recognized third party agency.
An income statement and balance sheet for the last 2-3 years (2015/2014/2013).
One professional head shot photograph. Specifics: a digital file minimum 300 dpi in jpg format.
Nominee’s name: Mr./Mrs./Ms./Dr.
Title:
Birth date:
Religion:
Company/Organization :
Phone:
Fax:
Address:
City:
Postal code:
Phone:
Email:
Assistant/Secretary:
Phone:
Email:
Website:
A. Information on
the organization
A.1. Succinctly state the mission of your organization: (1-2 sentences)
Please use additional
pages if required.
A.2. Geographic area of activity of the organization:
A.3. Year organization was established:
A.4. Which type of model best describes your organization? Please choose one option:
Leverage not-for-profit: A not-for-profit organization that commits a cross section of society, including private and public organizations as well as volunteers that drive forward the innovation through multiplier effect.
The organization depends on outside funding for its survival but its longer term sustainability is enhanced because of
the commitment of multiplicity of actors to the vision and objectives of the organization which often ends up
transcending the organization itself.
Hybrid not-for-profit: A not-for-profit but the model includes some degree of cost-recovery through sales of goods and services to a cross section of partnering institutions – public and private, as well as to target populations groups.
However, to be able to sustain the transformational activities in full and address the needs of clients, most who are
poor or otherwise marginalized from society, the organization mobilizes other sources of funds from the public and/or
the philanthropic sectors. Those funds can be in the form of grants or loans.
Social business ventures: A business that drives transformational change. While profits are generated, the main aim is not to maximize financial returns for shareholders but to grow the social venture and reach more people in need effectively. Wealth accumulation is not a priority – profits are reinvested in the enterprise in order to fund expansion. Investors in the organization are interested in combining financial and social returns on their investments.
Comments:
3. Direct social impact
a. How tangible are the results of the initiative to date?
Not proven yet whether or to what extent people’s lives have been improved.
Results sufficient to surmise that people’s lives were improved, but documented evidence still limited or lacking in proof.
Rudimentary evidence shows tangible impact on people’s lives with supportive quantitative and qualitative documentation.
Evidence is convincing of significant tangible improvements in people’s lives, with substantial documentation.
Comments:
b. How are your tangible results measured?
4. Replicability
a. Which best describes how you expanded thus far? (please choose one option).
As your work has become more widely known (case studies, media coverage, advocacy through conferences, etc.),
a diverse array of third parties have copied the approach in other contexts.
Your enterprise has established partnerships with replicating entities who must adhere to overall goals, objectives and
methodology in exchange for permission to use brand.
Your enterprise has established affiliates in satellite settings. You control hiring satellite management, establish
procedures, and control quality.
Organic expansion by your organization. Direct oversight by central office.
Other. Please explain
b. How far could the initiative be expanded from its original group of beneficiaries?
Application may be restricted largely to initial beneficiaries.
Could be expanded to adjacent communities.
Could be expanded to neighboring states/departments of the country and/or other countries.
Extends into other countries already.
c. Please comment on your vision for future expansion:
5. Sustainability
a. What percentage of its budget does the organization generate through the sale of products, service or fees?
Between 0-20%
Between 21-50%
Between 51-75%
Between 76-100%
Comments:
b. How do you work in partnership with government, civil society, and companies? (max. 250 words)
c. To what degree is your organization dependant on government, philanthropic grants or donations? (please choose one
option).
0-25%
26-50%
51-75%
76-100%
How did you learn
about the
EY Entrepreneur Of
The Year program
EY
Entrepreneur Of The Year Winner/finalist
Entrepreneur Of The Year website
Entrepreneurial Winning Women Winner/finalist
Prior year participant/attendee
Sponsor
Direct mailing
Electronic media
Print media (Forbes
Indonesia /
)
Word of mouth
Banker
Attorney
Public relations firm
Other
A.5. Area of activity (check as many as apply):
Health
Enterprise development
Technology
Education
Other
Water/sanitation
Homelessness and housing
Rural development
Labor conditions
Communication/media
Fair trade
Environment
Microfinance
A.6. What problems do your organization seek to address? What does your organization do to address them?
(max. 150 words)
A.7. Describe the management team of the organization : (max. 100 words)
A.8. Please list your board members and their main occupations:
A.9. Indicate the number of:
Full-time staffs
Part-time staffs
A.10. Are your financial statements audited?
B. Information
on the founder
Yes
Volunteers
No
B.1. Tell us about yourself/the founder of the organization. What inspired you/the founder to spearhead the original idea?
(max. 150 words)
Please use additional
pages if required.
B.2. Time commitment: How much of your time do you invest in this organization?
Full-time
Part-time (indicate monthly percentage of time)
%
C. Meeting the
criteria
Please use additional
pages if required.
Please mark the box you feel best reflects you/your organization’s situation. Add comments you feel would be helpful.
1. Innovation
To what extent has the initiative introduced new approaches or offered new solutions to societal problems?
Approach or solution is applied by other organizations in the country with slight variations.
Approach or solution is new to the area or this region of the world, but similar ones are in place or practiced elsewhere.
Approach or solution was unknown prior to the initiative, but the innovation represents only a minor departure from
prior practice.
Approach or solution truly has discovered a unique way of using/combining resources, has discovered new resources
or services/service delivery methods.
Comments:
2. Reach and scope
a. Currently, how widespread is the initiative?
Spans several communities in one state/department. Spans several states/departments of a country.
Spans most of the country.
Spans more than one country.
Comments:
b. How many direct beneficiaries are there in total at this time?
Less than 5,000
Over 50,000
Between 5,000 and 15,000
Not applicable. Please explain (max. 100 words)
Between 15,000 and 50,000
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Declaration and authority to use information
About EY
I declare that the information provided in this nomination form and the attached
profile is true and correct.
EY is a global leader in assurance, tax, transaction and
advisory services. The insights and quality services we
deliver help build trust and confidence in the capital
markets and in economies the world over. We develop
outstanding leaders who team to deliver on our promises
to all of our stakeholders. In so doing, we play a critical
role in building a better working world for our people, for
our clients and for our communities.
EY refers to the global organization, and may refer to one
or more, of the member firms of Ernst & Young Global
Limited, each of which is a separate legal entity. Ernst &
Young Global Limited, a UK company limited by guarantee,
does not provide services to clients. For more information
about our organization, please visit ey.com.
About Entrepreneur Of The YearTM
EY Entrepreneur Of The Year™ is the world’s most
prestigious business award for entrepreneurs. The unique
award makes a difference through the way it encourages
entrepreneurial activity among those with potential, and
recognizes the contribution of people who inspire others
with their vision, leadership and achievement. As the
first and only truly global award of its kind, Entrepreneur
Of The Year celebrates those who are building and
leading successful, growing and dynamic businesses,
recognizing them through regional, national and global
awards programs in more than 145 cities in more than 60
countries. ey.com/id/eoy
© 2016 PT. Ernst & Young Indonesia.
All Rights Reserved.
I understand that the information I provide in this nomination form will be used
by EY Entrepreneur Of The Year in selecting award recipients and I consent to
the use of such information for that purpose.
I further consent to the use of such information for research, educational or any
purpose as long as such use does not divulge my identity or the identity of the
company, to any person other than the sponsors, the judges and their respective
affiliates.
If I am selected as a finalist or award recipient, I hereby authorize the release
and use, in connection with EY Entrepreneur Of The Year program,
of my name, my company’s name, non-financial information, photographs, video
or audio recordings of me in any form of media, from whatever source.
I agree that no compensation shall be due me or my company for such usage.
Nominee’s signature
Date
APAC No. 00000159
Submission and queries
Completed nomination forms should be sent to the following address or faxed to
+62 21 5289 5006 or email to [email protected].
SEOY submiision deadline is 31 July 2016.
EY Entrepreneur Of The Year Committee
Indonesia Stock Exchange Building Tower 1, 13th floor
Jl. Jend. Sudirman Kav. 52-53
Jakarta 12190
If you have any queries, please call the EOY Committee at +62 21 5289 5050.
Attach nominee’s business card
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