ESGAM Unsung Heroes 2025 Recognition Self-Declaration Form Section 1: Personal InformationFull Name(Required)Contact Number(Required)Email(Required) Current Position / Title(Required)Organisation(Required)Address(Required)Section 2: Contribution to ESG1. Description of ESG Contributions2. Highlight innovative approaches and the impact of these initiatives on the environment, society, and governance within Malaysia3. Duration of ContributionStart DateDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920OngoingYesNoEnd Date Day Month Year 4. Outcomes and Impact5. Stakeholder EngagementSection 3: Due Diligence Information1. Criminal Record: Have you ever been convicted of a criminal offense? No Other [If yes, please provide details]2. Bankruptcy: Have you ever declared bankruptcy or been involved in any bankruptcy proceedings? No Other [If yes, please provide details]3. Regulatory or Global Sanctions: Have you ever been subject to any regulatory or global sanctions and investigations? No Other [If yes, please provide details]4. Litigation: Have you ever been involved in litigation? No Other [If yes, please provide details]5. Politically Exposed Person: Are you a politically exposed person? No Other [If yes, please provide details]6. Conflict of Interest: Do you have any potential conflicts of interest that theaward committee should be aware of? No Other [If yes, please provide details]Section 4: Supporting Documentation1. Documentation and EvidenceAttach any supporting documents that can verify your contributions (e.g., reports, publications, awards, letters of recommendation, media coverage). Drop files here or Select files Accepted file types: jpeg, jpg, png, pdf, Max. file size: 20 MB, Max. files: 5. 2. Provide contact information for up to two references who can attest to your ESG contributions.References 1 Name RelationshipContact detailPhone numberEmail address References 2 Name RelationshipContact detailPhone numberEmail address Section 5: DeclarationSelf-Declaration(Required) I hereby declare that the information provided in this form is true and accurate to the best of my knowledge. I understand that any false information may disqualify me from consideration by ESG Association of Malaysia for the ESG Recognition. Δ
