Page One Nomination Form

Page Two

Name of the Nominee

Present Designation

Since

Present Affiliation

Significant Contribution of the Nominee (100 words)

Detailed contributions of the nominee towards the advancement of
Science and Technology and towards society (within 1000 words) [Upload a PDF file]

Past Employment:

Designation

Affiliation

From

To

Academic Qualifications:

Degree	Subject	Institution	Year
Bachelors
Masters
PhD

Fellowships and Associateship of Academies (check all that apply):

Associate of WAST Associate of INSA Associate of IAS Associate of NASI

Associate of INAE Associate of NAMS Associate of NAAS Fellowship of INSA (FNA)

Fellowship of IAS (FASc) Fellowship of NASI (FNASc) Fellowship of INAE (FNAE)

Fellowship of NAMS (FAMS) Fellowship of NAAS (FNAAS)

Abbreviations:
West Bengal Academy of Science and Technology (WAST)
Indian National Science Academy (INSA)
Indian Academy of Sciences (IAS)
The National Academy of Sciences India (NASI)
Indian National Academy of Engineering (INAE)
National Academy of Medical Sciences (India) (NAMS)
National Academy of Agricultural Sciences (NAAS)

Other Awards and Accolades

Page Three

Number of Extramural Projects Awarded

Details to be uploaded as the attached proforma [Upload a PDF file]

Name of the Funding Agency	Title of the Project	Role of the Nominee (PI/CoPI)	Amount	From (Year)	To (Year)	Status: Completed/Ongoing

Number of industrial/consultancy projects undertaken

Details to be uploaded as the attached proforma [Upload a PDF file]

Name of the Industry	Role of the Nominee (PI/CoPI)	Amount	From (Year)	To (Year)	Status: Completed/Ongoing

Details of Industrial Collaboration (Max 200 words)

Creation of facilities:

Name of the facility created

The purpose of creating the facility

Page Four

List of 10 best publications

Details to be uploaded as per the following format [Upload a PDF file]

Title of the paper, Name of all authors, Journal, volume, page, year, DOI

Upload merged PDF files of the 10 papers

Number of Total Publications in journals

Details to be uploaded as per the following format [Upload a PDF file]

Title of the paper, Name of all authors, Journal, volume, page, year, DOI

h-Index

Total number of citations as per Google Scholar

(Please ensure that all the publications listed in Google Scholar are of the nominee themselves)

Publications as books and book chapters:

Details to be uploaded as per the following format [Upload a PDF file]

Title of the Book, Name of all authors, Number of pages, Publisher, year, ISBN Title of the Book Chapter, Authors, Title of the Book, Editor of the book, Publisher, page (from/to) year, ISBN

List of Patents/Copyrights:

Details to be uploaded as per the following format [Upload a PDF file]

Application/Grant No, Date of Application/Grant, Name of the Applicant, Name of the inventor(s), Impact on Industries/ Society

Number of Publications in Conference Proceedings

Details to be uploaded as per the following format [Upload a PDF file]

Title of the paper, Name of all authors, Name of Conference, Venue, Year, DOI

The nominee must declare details of publication retractions (and reasons thereof), if any, in the past five years:

Editorial Activities for Journals

Page Five

Number of PhD guided

Details to be uploaded as per the following format [Upload a PDF file]

Name of the PhD student	Thesis title	Institute	Single/Joint	Year

Number of Master’s theses guided

Details to be uploaded as per the following format [Upload a PDF file]

Name of the Master's student	Thesis title	Institute	Year

Teaching of UG/PG courses

Details to be uploaded as per the following format [Upload a PDF file]

UG/PG	Name of the Course	Institute

Upload the signature of the nominee format [Upload a jpg/png file]

Preview

View the Nomination Form

After submittion

The Nominee will save the PDF file and send it to the Proposer/Seconder for their e-signatures. The Proposer/Seconder will have to send the e-signed Nomination Form (PDF file) to the Academy at