Section Awards Nomination Form for the Year 2014
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)