*Mandatory fields

*1. Name of the Nominee (in block letters): ……………………………………………………………..

(should not be more than 35 as on 31.03.2018)

*2. Age:

*3. Date of Birth:

d d / m m / y y y y
(Proof to be enclosed)

*4. Engineering Discipline: (To be selected from following 15 Engineering Disciplines)

(Applied for)
(Agricultural Engg: AG, Architectural Engg: AR, Aerospace Engg: AS, Chemical Engg.: CH, Civil Engg: CV,
Computer Engg.: CP, Electrical Engg: EL, Environmental Engg.: EN, Electronics & Telecomm. Engg.: ET,
Mechanical Engg: MC, Marine Engg.: MR, Metallurgical & Materials Engg.: MM, Mining Engg: MN, Production Engg.: PR,
Textile Engg.: TX)

*5. Sex: Male / Female M F

*6. Address (with PIN code):

(A)*Office / Institute: (B)*Residence:

Please tick the address for correspondence (A/B)

*7. Email:

8. Phone (with STD code): *Mobile:

9. Classification of contribution:
Duration Years
From To
(a) Academics/ Research

(b) Industry/Industrial Research/Engineering Design/

Engineering Consultancy

10. Academic Qualification (Bachelor’s Degree Onwards):

(signature of Nominee with date) (signature of Nominator with date & seal)
 Degree University / Institution Division / Year of Specialisation
Equivalent Passing
B.Tech /
B.E./AMIE

M.Tech /
M.E.

Ph.D

11. Experience Details (In reverse chronological order):

Institute / Organisation Type Post Held From (date) Nature of Job

(Academic Instt./ To (date)
Industry / Self-
employed)

12(a). Papers Published in National / International Journals / presented in National /

International Conferences:

(signature of Nominee with date) (signature of Nominator with date & seal)
(Copies of first pages of the papers have to be attached)

Name of all Paper Title Name of Journal ISSN No. Vol, No., Month, DOI of
Authors Year, pp the paper

12(b). Contribution to Engineering Design, Improvement in processes / plant operation /

operating parameters, Technology / Product Development, Technology Transfer, Project
Implementation/management, site modification resulting in improvement in productivity
/ safety / breakdown of plant & equipment / import substitution:
(Copies of supporting documents have to be attached)

List of Designs, Products, Place where used Year of Benefit achieved

Process, Project Implementation implementation / use (if any)

13. Patents / Copyrights:

Item Patent/Copyright No Year Granted by

(signature of Nominee with date) (signature of Nominator with date & seal)
14. Contribution in the area of sustainable development:

Brief about contribution Place where used Year of Benefit achieved

implementation / use (if any)

15. Technical Books /Book Chapters / Project Report / documents (Nominee should be
either Author / co author / or member of task force:
[Copies of title page(s) of the book/s / documents has/have to be attached]

Title Publisher Year of Publication ISBN No

16. Course Material / Norms / Engineering codes developed [including online

courseware]:

(Necessary documents in support of claim should be enclosed)

Course Target Group Reference/Web link

(signature of Nominee with date) (signature of Nominator with date & seal)
17. Contribution in improving energy efficiency, environment, and make in India efforts
in your area of operation (Should be different from Sl. No. 14):

Brief about contribution Place where used Year of

implementation /
use

18. Awards / Distinction received by the nominee:

(Copies of certificates to be enclosed)

Name of the Award Details of contribution related Awarded by Year Type

to the Award (National /
International)

19. (a) Membership of The Institution of Engineers (India), if any, with category and
membership number

Fellow / Member / Associate Member Membership No.:

19 (b) Membership of other Professional Societies, if any, with category of membership:

(copy of Membership Certificate / Letter to be enclosed)

(signature of Nominee with date) (signature of Nominator with date & seal)
 Name of the Society Address Membership Category &
Number

20. Any additional information of relevance (not more than 200 words):
(Social contributions, Organizing Technical Seminars, Conferences, Workshops etc.)

(signature of Nominee with date) (signature of Nominator with date & seal)