12. Degrees Obtained at IIT Kharagpur *
Degree Awards (e.g. PGM / Silver Medals etc.) Department Branch or Specialization Hall of Residence Passing Year
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13. Other Academic Qualifications
Degree Institution Passing Year Awards/ Distinction
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14. Professional Achievements *
Period From Period To Position Held Organization/Institution Role Remarks
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15. Record of Contributions to the suitable items mentioned from (a) to (f) (within 100 words in each section)

16. Peer Recognition (National/International Honours, Awards, Prizes including honorary degree) (within 300 words)

17. Membership/Fellowship of National/International Professional Bodies (within 300 words)

18. Specific outstanding Accomplishments meriting the award (within 300 words as per the proposer)

19. Please select one of the below (the proposed candidature may be categorized under one of the below mentioned categories)

20. Proposer Details
Name and Address of the Proposer *

21. Seconder Details
Name and Address of the Seconder *

22. Upload CV in Doc/Pdf foamt (max 4 pages) *
23. Photo of the Nominee in jpg format (Upload)*