NOMINATION FORM – THE BETTER INDIA HEALTHCARE AWARDS, 2018 Nomination Type Individual Organization Name of the Nominee Name of the Clinic/ Hospital/ Organization Year of Establishment Address for Communication Official Website TelePhone/ Fax Number E-Mail ID Name of the Chairman/ Director/ Head/ Proprietor Mobile No. Name of the Contact Person & Designation E-Mail ID Mobile No. Products/ Services/ Specialization Nomination Category Sub-Category Annual Turnover Please Select Nomination Level National Level Zonal Level State Level City Level Nomination Level Do You Want to Nominate for Multiple Levels? Yes No Please Select 2nd Nomination Level National Level Zonal Level State Level City Level 2nd Nomination Level Previous Awards & Achievements (if any) Accreditations & Certifications (if any) Invitation sent by (Please Select) Akshat Amreen Anuradha Aradhana Minakshi Monika Nisha Poonam Priya Rajeev Invitation sent by Attach Profile/ Brochure/ Prospectus Remarks/ Comments (if any) Acceptance of Terms & Conditions* By filling and submitting the nomination form, I admit and declare that I have read and understood the Application and Selection process and the Terms and Conditions of the Better India Healthcare Awards, 2018. I hereby agree and accept the same. I further admit and declare that information provided in the nomination form is true to the best of my knowledge and belief.