For Office Use

2/5, Krishna Industrial Estate, Mettukuppam,

Vanagaram, Chennai, India -600 095.
E-mail: query.irdp@gmail.com
Cell: +91-9042494130 WhatApp: +91-9444706381

APPLICATION FORM FOR - PRESTIGIOUS IRDP AWARD 2018

1. Award Category (Tick the appropriate box)

1. 9. 17.

2. 10.

3. 11.
Photo
4. 12.

5. 13.

6. 14.

7. 15.

8. 16.

2. Full Name of the Applicant (in Capital letters):

3. Date of Birth : DD/MM/YYYY 4. Age : years

4. Gender : Male Female Trangender

5. Marital Status : Married Unmarried

6. Phone Number (House) :

7. Cell Number :

8. Phone Number (Office) :

9. E-mail id :

10. Alternate E-mail id :

1
11. Address for Communication :

12. Permanent Address :

13. Educational Qualification :

(Attach self attested copy of Highest Qualification)

14. Area of Specialization :

15. Designation :

16. Official Address :

17. Experience

A. Teaching years

B. Research years

C. Post Ph.D. years

D. Industrial years

E. Total years

18. No. of Scholars awarded : Ph.D. M.Phil.

19. No of Scholars doing : Ph.D. M.Phil.

20. Research Details

A. Journal Publications (in numbers) : Scopus Indexed Non-indexed

B. Conference Publication (in numbers) : with ISBN without ISBN

C. Books Published (Author) :

D. Books or Chapters (Co-author) : Books Chapters

E. Presented Papers : National International

F. Training Programs attended : more than 2 Weeks more than 4 Days

(FDP, Workshop, Orientation, Refresher)
Others
2
 G. Research Projects : Completed Doing
(Furnish the details separately)

H. Guest Lectures / Resource talk : Guest Lectures Resource Talk

: Session Chair

I. Patents / Copy rights :

J. Awards received :

21. Membership details

A. DD No./ NEFT No./ Cheque No. :

B. Date :

C. Bank :

D. Location :

22. Award Ceremony : Attend In-absentia

(Ceremony date will be informed later. For In-absentia, Certificate , Medal and Memento will be send by post)

23. Check list for Attachments (self attested)

A. Latest resume

B. Certificate of highest qualification

C. Research project details, if any

D. Resourch talk details, if any

E. Patent / Copyright details, if any

F. Received Award Copy, if any

G. DD / Cheque / Copy of NEFT

24. Declaration

I hereby declare that all the above information given by me in the application is true, complete
and correct to the best of my knowledge and belief and nothing has been concealed or distorted.

Date : Name :

Signature :

* All fields are not mandatory, since it is common for all category of applicants.