STATE AWARD FOR SCIENTISTS AND ENGINEERS

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(Instituted by Government of Karnataka)

PROFORMA

Nomination for ...................................................State Award
for the year 2011
1.	Personal Data:
1	Name		
2	Date of birth*		
3	Place of birth		
4	Period of stay in Karnataka**		
5	Present Position Held		
6	Address : (Office & Residence		
7	Tel no: (Off : Res : & Mobile)		
8	E-mail		
Note: * Enclose proof of age ** Enclose self-attested domicile certificate clearly indicating period of stay in Karnataka (as Annexure -I)

2.	Academic Qualifications:
(Indicate your educational qualifications, starting with latest)
Period	Qualification	University / Institute/ Board	Subject / field	

3.	Professional Career
Indicate your professional career for the past 20 years, starting with the latest.
Period	Years	Organization	Designation	Nature of work / responsibility 	
					
Profile professional career/life sketch : (Write-up not to exceed 300 words) 	

4.	Area of Professional Activity (any of the areas listed below)
•	Life Sciences
•	Physical Sciences & Mathematics
•	Chemical Sciences
•	Agricultural Science and Animal Husbandry
•	Medical Sciences
•	Aerospace Science and Technology
•	Earth Science
•	Engineering Science
•	Computer and Electronics Engineering
•	History & philosophy of science/ Science & Society/ Science Education

5.	Research Papers/ Publications (Only those publications printed before March 2011 to be included)

5.1 Summary of Publications (Please indicate numbers only)
	Publications	Numbers	
a	Papers published in journals		
b	Papers published in conferences / seminars 		
c	Articles published in newsletter / bulletin		
d	Books 		
e	Chapters in Books		
f	Reports		
g	General / popular articles 		
h	Other types publications, if any		
i	Patents granted		

5.2 Details of Publications: (Please give details as indicated below)
a.	Papers published in journals (Title, Author & Co-authors, Journal, Volume, Year of publication and Page Numbers)
b.	Papers published in conferences / seminars (Title, Conference / seminar, Date & Venue, Page Numbers)
c.	Articles published in newsletter / bulletin (Title, Author & Co-authors, Journal, Volume, Year of publication and Page Numbers)
d.	Books / Chapters (Title of Book/ Chapter, Author & Co-authors, Volume, Year of publication and Page Numbers)
e.	Reports/ Popular articles Other types publications, if any (Title, Author & Co-authors, Publisher, Year)

6.	Patents (Please indicate details : Title, Patent Number, Year & Country)

7.	Guidance to Students (PG and Ph.D) : (No. of students awarded & No. of students still working)

8.	Fellowship / Membership of professional bodies: (only during professional carrier)

9.	Awards & Citations received (Only during professional, not as student)

10.	Details of five important research publications: Copies of all such papers to be sent as Annexure-II
	(Which you think should be taken into consideration for this award. This should include Title and details of publication/ Contributions, Brief description of work)

11.	Details of two referees (Letters should be enclosed as Annexure-III)

Name & Designation	Address	Areas of research	Relationship with referee	

12.	Any other information you would like to furnish to justify your nomination for the award
(Supporting document, if any, to be attached as Annexure IV)

13.	Declaration:
I, ..................................................., hereby, declare that all the information provided by me in this proforma for the nominations for ................................. State award (instituted by Government of Karnataka) for the year ........................ are true to best of my knowledge. I would provide the original documents if required.

Date:

Place:									Signature