Nomination Form for the Distinguished Service Award of
IIT Kharagpur 2023

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)

16. A short write-up on the service to IIT Kharagpur meriting the award (within 100 words)

17. Proposer Details
Name and Address of the Proposer *

18. Seconder Details
Name and Address of the Seconder *

19. Upload CV (max 4 pages) *
20. Photo of the Nominee in jpg format (Upload) *