Nomination Form for the Distinguished Service Award of
IIT Kharagpur 2023
1. First Name
*
2. Last Name
*
3. Date of birth
*
4. Residential Address
*
5. Phone/Mobile (Whatsapp No.)
*
6. Current Email Address
*
7. Profession
*
8. Present Position /Last held Position (if retired)
*
9. Official Address
*
10. Phone/Mobile
*
11. Fax:
12. Degrees Obtained at IIT Kharagpur
*
Degree
Awards (e.g. PGM / Silver Medals etc.)
Department
Branch or Specialization
Hall of Residence
Passing Year
Add New Row
13. Other Academic Qualifications
Degree
Institution
Passing Year
Awards/ Distinction
Add New Row
14. Professional Achievements
*
Period From
Period To
Position Held
Organization/Institution
Role
Remarks
.
Add New Row
15. Record of Contributions to IIT Kharagpur Community in one or more of the suitable items mentioned from (a) to (m) (within 100 words in each section)
(a) Number of years of service to the Alumni Chapters/Foundations and tangible achievements made
Supporting Document if any (Upload)
(b) Number of Alumni-related events organized by the nominee, capacity in which organized, the number of participants in each, tangible outcome in the form of donations collected, etc.
Supporting Document if any (Upload)
(c) Endowments created for Chair-Professorships, Scholarship, Centres, Schools, Academy, Lab and other needs of the Institute:
Supporting Document if any (Upload)
(d) Participation at IIT Kharagpur as Adjunct Faculty
Supporting Document if any (Upload)
(e) Joint research collaboration with the faculty of the Institute
Supporting Document if any (Upload)
(f) Mentoring of students/faculty in innovation and entrepreneurial ventures
Supporting Document if any (Upload)
(g) Financial support to the Institute through CSR Fund from the Industry
Supporting Document if any (Upload)
(h) Initiative for Industry-Academic collaboration in research & product development
Supporting Document if any (Upload)
(i) Collaboration with IIT Kharagpur in lab to market initiative, product licensing
Supporting Document if any (Upload)
(j) Participating in designing new courses and courses in the interdisciplinary areas
Supporting Document if any (Upload)
(k) No. of International collaboration established like Joint Ph D, Student exchange Programe, Joint Research etc
Supporting Document if any (Upload)
(l) Financial support to the Institute incubated Startups
Supporting Document if any (Upload)
(m) Recognitions received within the Alumni fraternity
Supporting Document if any (Upload)
16. A short write-up on the service to IIT Kharagpur meriting the award (within 100 words)
Supporting Document if any (Upload)
17. Proposer Details
Name and Address of the Proposer
*
Batch(es)
Degree(s) Obtained at IIT Kharagpur
Hall(s) of Residence(s)
Email
*
Qualifying Criteria
*
DAA
DSA
YAAA
Life Fellow
Foundation Office Bearers
Senate Members
Others (Ex Senate Members/Former Office Bearers of Foundation)
Others - Please Mention
Signature of the Proposer in jpg format(Upload)
*
18. Seconder Details
Name and Address of the Seconder
*
Batch(es)
Degree(s) Obtained at IIT Kharagpur
Hall(s) of Residence(s)
Email
*
Qualifying Criteria
*
DAA
DSA
YAAA
Life Fellow
Foundation Office Bearers
Senate Members
Others (Ex Senate Members/Former Office Bearers of Foundation)
Others - Please Mention
Signature of the Seconder in jpg format (Upload)
*
19. Upload CV (max 4 pages)
*
20. Photo of the Nominee in jpg format (Upload)
*
Submit