STATE AWARD FOR SCIENTISTS AND ENGINEERS

Latest Photograph 

(Instituted by Government of Karnataka)

PROFORMA

Nomination for ...................................................State Award 
for the years 2015 and 2016
1.0	Personal Data:
1	Name		
2	Date of birth*		
3	Place of birth & State		
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. Applicable only to those who are not born in Karnataka (as Annexure -I) 

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

3.0	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.
Please submit the write-up both in Kannada and English) 	

4.0	Area of Professional Activity  (any of the areas listed below)
•	Physical Sciences & Mathematics
•	Chemical Sciences
•	Medical Sciences
•	Life Sciences
•	Agricultural Science and Animal Husbandry
•	Engineering Sciences (specify sub field)
•	Science Education / History & philosophy of science/ Science & Society

5.0	Research Papers/ Publications (Only those publications published on or before 28th February of the respective award year 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)

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

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

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

9.0	Awards & Citations received  during professional career. (Please do not include the awards received during studentship and for other activities) 

10.0	Details of two referees (Letters should be enclosed as Annexure-II)
Name & Designation	Address	Areas of research	Relationship with referee	

11.0	Details of five important research publications: 
Copies of all such papers to be sent as Annexure-III

(Which you think should be taken into consideration for this award. This should include Title and details of publication/ Contributions, Brief description of work)

12.0	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)

13.0	 Declaration:

I, ..................................................., hereby, declare that all the information provided by me in this proforma for the nominations for ........................................State Award for the year 2015 / 2016  are true to best of my knowledge. I would provide the original documents if required. 

Date:

Place:								Signature