Distinguished Alumni Award

“JEWEL OF MIT PUNE - 2013”

Nomination Form

Instruction for filling the Application Form:

i.  Kindly fill the form in CAPITAL LETTERS. The form should be complete in all respects.

ii.  Incomplete forms will not be considered and will be rejected.

iii.  Last date for receipt of completed form is 19 January 2013 by 3.00 pm

iv.  Send the complete form to :

JEWEL OF MIT, PUNE Awards Committee, MAEER’s MIT Group of Institutions, Survey No 124, Paud Road, Kothrud, Pune 411038, Maharashtra

v Kindly use the photocopy this same nomination form in case of nominations in multiple categories.

vi Applicant should be the past student (Graduate) of MAEER’s MIT, PUNE.

vii Online nominations can be filled and sent to

Details of Applicant

1 Name: Mr./Ms/Mrs.………………………………………………………………………..

(LAST) (FIRST) (MIDDLE)

2 Sex Male Female 2a Marital Status: Married/Unmarried

3 Nationality……………………………… 4 Domicile State …………………………………

5 Address for Correspondence……………………………………………………………………….

………………………………………………………………………………………………………

…………………………Pin Fax ……………………

E-mail:………………………………………………. Mobile ………………………………

6 Permanent Address (If different)……………………………………….……………………..

………………………………………………………………………………………………………

…………………………Pin Fax ……………………

E-mail:………………………………………………. Mobile ………………………………

If employed then Office Address …………………………………………………………………..

………………………………………………………………………………………………………...

Phone/Fax ……………………………………………………………………………………………

7 Father’s Name……………………………………… Mother’s Name…………………………

Profession …………………………………………………………………………………………

Tel/Mobile…………………………………………………………………………………………

Office Address ……………………………………………………………………………………..

………………………………………………………………………………………………………...

8 Employment of the Applicant :(If self employed then the details)………………………………..

………………………………………………………………………………………………………...

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9 Academic Qualifications of the Applicant:

MIT Pune Year of Graduation:……………………………….. Branch ………………………

Post MIT, Pune Graduation Details

Sr. No / EXAMINATION
Degree/Diploma/Other / AREA OF SPECIALISATION STUDIES/SUBJECTS / YEAR OF PASSING / NAME OF SCHOOL/COLLEGE ATTENDED / UNIVERSITY

10 Details regarding Academic Awards/Medals/Prizes/Scholarships/Honors etc. (Attach the copy)

………………………………………………………………………………………………………..

………………………………………………………………………………………………………..

………………………………………………………………………………………………………..

11 Professionals Awards/Medals/Prizes/Scholarships/Honors etc. (Attach the copy)

………………………………………………………………………………………………………..

………………………………………………………………………………………………………..

………………………………………………………………………………………………………..

12 Notable contribution for which you consider yourself eligible for JEWEL OF MIT AWARD - 2013.

……………………………………………………………………………………………………….

………………………………………………………………………………………………………..

………………………………………………………………………………………………………..

Date……………….. Signature of the Applicant………………………

Ø  Last date of submission of completed application form is 19 January 2013, by 3.00 pm

Ø  Please address your nomination form to:

MAEER’S MIT GROUP OF INSTITUTIONS, Survey No. 124, Paud Road, Kothrud, Pune – 411038. Maharashtra with envelope entitled “for JEWEL OF MIT PUNE 2013”