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  Section A
                                                                                                      Who’s eligible?
                                                                                                      Learners who have completed an
  Learner details                                                                                     ILM qualification, endorsed or
                                                                                                      development programme during
Title (Ms, Mr , Mrs etc)
                                                                                                      the period 1 September 2009 to
First name                                                                                            31 August 2010 are eligible for
                                                                                                      entry. Previous regional/national
Surname                                                                                               winners cannot enter for the
Date of birth                                                                                         Award again.

Job title                                                                                             Nominated by
Company name                                                                                          Learners themselves
Company address                                                                                       ILM centres/providers

                                                                                                      The overall ILM Learner of the
                                                                                                      Year will be selected from the
                                                                                                      winners of the following
Town                                         County                                                   regions/nations:
                                                                                                      • England
Postcode                                     Country                                                  • Wales
Telephone                                                                                             • Scotland
                                                                                                      • Northern Ireland
Mobile                                                                                                • International
Email                                                                                                 Regional/national winners will be
Which ILM qualification or programme did you complete (including level)?                              invited to a regional award
NB please copy the exact title from your ILM certificate                                              ceremony in January/February
                                                                                                      2011 and also to the national
                                                                                                      ceremony, to be held in London in
What date did you start the course?                                                                   April 2011, where the ILM Learner
                                                                                                      of the Year prize will be presented.
What date did you complete the course?
ILM centre name (where you did your course)?                                                          The decision of the judges is final
                                                                                                      and no correspondence will be
                                                                                                      entered into.
ILM centre number (if known)
                                                                                                      To enter
ILM centre address                                                                                    Complete the form in Word format
                                                                                                      and email to:

                                                                                                      The closing date for entries is
Town                                         County                                                   Thursday 30 September 2010
                                                                                                      Late entries will not be considered.
Postcode                                     Country
Which region are you entering for? (delete as appropriate)                                            You will receive an email
England     Wales       Scotland   Northern    Ireland International                                  acknowledging your entry by
If the nomination is being made by an ILM centre or provider, please give your details below –        Friday 1 October. You are
otherwise leave this section blank                                                                    responsible for checking we have
Title (Ms, Mr, Mrs etc)                                                                               received your entry.
First name                                                                                            Call 01543 266855 (Monday to
Surname                                                                                               Friday 9-5) if you have any
Job title
Mobile                                                                                                     ILM reference number

ILM centre number

                                                                      ILM learner of the year entry form_July 2010_word_v5 Page 1 of 4
Section B – the learner
Please tell us about your role and responsibilities and how your achievement of an ILM qualification/programme has contributed to the
success of your organisation, business or community (up to 500 words)                                                      20 marks

                                                                    ILM learner of the year entry form_July_2010_word_v5 Page 2 of 4
What is remarkable about the work you submitted as part of the ILM qualification or programme (eg did you achieve exceptionally high
marks, was the quality of your work commended and, if so, who by?)              (up to 200 words) 20 marks

Why is your story an inspiration to others to learn and develop themselves (up to 200 words) 10 marks

Total word count for Section B
                                                                   ILM learner of the year entry form_July_2010_word_v5 Page 3 of 4
Section C – referee (this section is only for learners who are self-nominating)
Please provide a short reference from a second person such as your line manager, your ILM tutor or assessor.

Name of referee
Signature of referee (can be electronic)                                                     Date

Company name
Relationship to nominee
Email address
Section D – publicity (to be completed by the learner or ILM centre/provider)
There is always media interest in the ILM Learner of the Year. Please give details of the person who can respond most effectively
to publicity enquiries, for example a marketing/communications officer or press officer at work or at your centre.
Job title
Daytime phone number
Mobile phone number
Email address
What is your local radio station?
What is your local newspaper?
I confirm that the information supplied above is correct to the best of my knowledge and that the statements are true and accurate. I also
confirm that I have read and agree to the conditions of entry into the ILM Learner of the Year 2011 (see front page of form).


Signature (can be electronic)                                                                   Date

                                                                     ILM learner of the year entry form_July_2010_word_v5 Page 4 of 4

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