Keba Mbaye Prize Of Ethics 2014
Nomination form
(Only in French or English)
Self-nomination will not be taken into account.
Information about the organization or the person putting forward the nomination
Organization
NGO Name & Acronym:
Other Organization Country:
Responsible person :    
Physical person
Sir Mrs
First name: Last name:
Nationality : Age:
Contact details
Address: Une valeur est requise. Email: Une valeur est requise.Format non valide.
Website:    
Nomination
Institution
Name & Acronym:    
Date of creation Place of creation
City or country head office: Field of activity:
Individual application
Sir Mrs
First name:: Last name::
Date of birth Place of birth
Nationality Training:
Profession :    
Contact details
Address: Email:
Fax: Tel:
Website:    
Stated point of view: (You can complete by attached text)

Form to complete and return before June 30th 2014 at midnight (GMT) at:
Keba Mbaye Foundation «Ethics and Solidarity » - Executive Secretary
Rue G x Leon Gontran Damas - BP 5865 Dakar Fann
Phone : +221 33.825.96.02 Fax : +221 33.825.96.06
Email : contact@fondationkebambaye.org