1. First Name
*
2. Last Name
*
3. Date of birth
*
4. Residential Address
*
5. Phone/Mobile
*
6. Email
*
7. Profession
*
8. Present Position
*
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
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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
.
Add New Row
15. Record of Contributions to the suitable items mentioned from (a) to (f) (within 100 words in each section)
(a) Intellectual Property (Publications/Design/Developments/Patents etc.)
Supporting Document if any (Upload)
(b) Leadership (Entrepreneurship/ Organizational Development)
Supporting Document if any (Upload)
(c) Society:
Supporting Document if any (Upload)
(d) Alma Mater (Connection and Contribution)
Supporting Document if any (Upload)
(e) Growth and development of the country
Supporting Document if any (Upload)
(f) Any other
Supporting Document if any (Upload)
16. Peer Recognition (National/International Honours, Awards, Prizes including honorary degree) (within 300 words)
Supporting Document if any (Upload)
17. Membership/Fellowship of National/International Professional Bodies (within 300 words)
Supporting Document if any (Upload)
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)
Academic & Research
Science and Engineering
Administrator/Leadership (Corporate/Government)
Entrepreneurship
Industry
Art & Culture
Nation Building and Social Welfare
Others
Others - Please mention
20. 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)
*
21. 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)
*
22. Upload CV in Doc/Pdf format (max 4 pages)
*
23. Photo of the Nominee in jpg format (Upload)
*
Submit