Computer Society of IndiaTM

Education Directorate, National Headquarters

ED Award Form-5 Version 3.0
CIT Campus, IV Cross Road, Taramani, Chennai 600 113
Phone: 044-2254 1103 / 2874 Website: www.csi-india.org email: edawards@csi-india.org

Scan
Passport
size
Photo of
the
candidate

Nomination for Longest Continuous SBC Award

(Awarded to the Student Branch Counsellor with longest continuous tenure at one or more colleges as SBC
over the past 3 years)

(For self nomination by Student Branch Counsellor)

1) Name of the SBC nominating self: _______________________________________________
2) Current Institution: ____________________________________________________________
3) Postal Address: ______________________________________________________________
___________________________________________________________________________
City: ________________________________________ PIN: __________________________
State: _______________________________________
4) Phone No. ___________________ Email ID: _______________________________________
5) Name of the Head of the Institution: ______________________________________________
6) Designation:________________________ Email ID: _________________________________
7) SBCs Email ID: ___________________________________ Mobile: ____________________
8) Institution Membership Number: _________________ Valid till: ______________________
9) Candidates CSI Membership Number: ___________________ Valid till: ________________
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10) Number of CSI Volunteers as on 30 June 2016:

_____________

11) Number of CSI Volunteers added during July 2016 June 2017: _____________
12) SBC tenure details:
Year

Name of the Institution

Institution
membership No.

No of CSI
Volunteers

2013 2014
2014 2015
2015 - 2016

Declaration
We declare that the above statements are true to the best of our knowledge and belief. If anything is
found wrong / incorrect, we understand our application is liable for rejection.
Place:
Date:
Signature of Head of the Institution with Seal

Relevant documents & completed application are to be sent to edawards@csi-india.org

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on or before 7 October 2016 with the subject of the mail as Academic Awards 2016.