1st Sonia R.

Lorenzo Award
for Women in Leadership and Good Governance

Application / Nomination Form

Please fill up necessary details. If nomination, please begin at no. 1. If Application, please proceed
to no. 2.
Email the completed form along with an updated curriculum vitae of the applicant/
nominee to srlaward@gmail.com. Use SRL Application or SRL Nomination as email subject.

1.

Name of nominating person

(if nominee):

Relationship to
nominee:

Phone:

Email:

2.

Name of applicant/nominee:

3.

Contact details:

4.

Phone:

Email

Current position in local

government/name of LGU:

5.

Former position in local

government/name of LGU:

6.

Number of years in
government service:

7.

Has applicant/nominee been convicted of any administrative

offense? (Please check box after the answer.)
Has applicant/nominee been convicted of any criminal
offense? (Please check box after the answer.)

8.

Yes

No

Yes

No

9.

Initial Qualifications: Please identify and briefly describe activities, programs and projects that
support the following:
a. Leadership
Experience:

b. Community Service:

c. Good Governance
Promotion:

d. Women
Empowerment: