Your Name*
Your Email*
Nationality* (Please upload pdf of PAN/Passport/Voter Card/Driving License/
Aadhar … maximum 2MB))
Gender* MaleFemaleOther
Date of Birth*
Address*
Pin code*
Mobile No*
WhatsApp No*
CV*: As per format provided (Please attach certificates/document as proof of qualification, maximum 2 mb))
Diabetes Educator attached to Doctor/Clinic/Others*
Justify your nomination in few words (maximum 400 characters)*
Ten cases of patients with diabetes benefited with your counseling during the year 2023-24 (Please attach document as per format provided, maximum 2 mb)*
Any other achievements in the field of diabetes like publications, recognition/honors etc.* (Please attach the documents as per format provided, maximum 2 mb))

Name of the doctor who recommended*
Phone no of the doctor who recommended*
Email of the doctor who recommended*
The informations are correct to the best of my knowledge. My nomination / award may be cancelled if any statements/informations proves false afterwards and I will support wholeheartedly to fulfill my roles & responsibilities being the winner of this award. .