Alumni Association

Indian Institute of Technology Kanpur

Satyendra K. Dubey Memorial Award -- Nomination Form

Name *

Home Address

Home Address    
City If any other please specify
State If any other please specify
Zip    

Business Address

Job Title    
Business Name
Business Address
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State If any other please specify
Zip    
Telephone Fax
Email    
Graduation year,
degree, branch at IIT






Other higher education
degrees (please specify institutions)
It is requested that nominations be accompanied by as much relevant material (in form of bio-data, Newspaper articles/profiles, information on other awards and commendations etc.) as is possible for the nominator to supply. Attachments can include, but is not limited to career/professional highlights, membership/leadership in professional organizations, professional honors, awards and/or recognition, publications, or noteworthy special work. Service to the community and/or civic organizations: can include, but not is limited to involvement with Institute, college or department committees, Alumni Association support, participation and membership, financial contributions, participation in University programs, teaching at the Institute, other volunteer membership, leadership or service. Can also include leadership, membership or support of civic organizations, charitable organizations, religious organizations, or other community related volunteer or financial support.
  

(Note : only .doc, .pdf, .jpg & .gif files can be uploaded & file size not more then 200kb.)


Nominator Information

Name *    
Degree/Branch/Pass Year *




Address *
City *
If any other please specify
State *
If any other please specify
Zip    
Telephone * Fax
Email *    
  


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