UTTAR PRADESH SECTION
APPLYING FOR
Outstanding Branch Counselor/ Chapter Advisor Award
Best Student Branch/ Branch Chapter Award
Outstanding Section Volunteer Award
Largest Student Branch Award
Note: If any point is not related to your nomination category, kindly write “NA”.
NAME OF BRANCH/ BRANCH CHAPTER-
BRANCH/BRANCH CHAPTER CODE NO.-
BRANCH/ BRANCH CHAPTER YEAR OF ESTABLISHMENT-
BRANCH COUNSELLOR/ BRANCH CHAPTER ADVISOR / STUDENT VOLUNTEER NAME-
IEEE MEMBERSHIPNO.-
IEEE MEMBERSHIP GRADE & SINCE -
E MAIL ADDRESS-
DATE OF BIRTH-
POSTAL ADDRESS-
PHONE MOBILE NO-
EDUCATIONAL QUALIFICATIONS-
EXPERIENCE-
NAME OF PROPOSER-
IEEE MEMBERSHIP NO
GRADE OF PROPOSER
TELEPHONEMOBILE NO-
EMAIL ID-
SIGNATURE WITH DATE-
CONTRIBUTION TO IEEE:
1. / Holding any Position in IEEE Present or Past ( in chronological order)Year of Joining / Establishment / Name of the Position / Outstanding Achievement/Contribution and its Impact/Benefits
Last two year strength:
2. / Membership / Role in conducting IEEE Events (Conference, Seminar, Workshop, Symposium and any other technical events)
Membership Count / Addition of new members in number / Addition of new members in percentage
Till December (last year)
Till today
3. / Role in promotion of IEEE membership in particular Branch /Branch Chapter
Individual Membership / Student Membership
4. / Professional Membership in other Societies
5. / Publication details in IEEE Journals/ Conferences/ Magazines/ Newsletters
6. / New ideas, developments or projects which have significantly benefited the Uttar PradeshSection
7. / Administrative ability
8. / Leadership Ability
9. / Further the work and promoting the objectives of the IEEE Student Branch/Branch Chapter level, or in some other IEEE Volunteer activity
10. / List the activities organized /participated/supported during the Year
11. / Contributions towards Humanity
12. / Other Relevant Information
DECLARATION
I do hereby solemnly affirm and declare on behalf ofme and/orIEEE______executive committeethat the above information given by me is correct to the best of my knowledge and belief.
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Date (Nameand Designation)
APPROVED/ DISAPPROVED BY AWARDS COMMITTEE WITH COMMENTS
Date: Convener (Awards Committee)
______
(Name & Signature)
Approved
Section Chairman
(Name & Signature)