PROFORMA FOR NOMINATION FOR

KERALA STATE YOUNG SCIENTIST AWARD

1. Name in Full ( Block Letters) :

2. Present Institutional Address, with telephone - : Landline & Mobile, fax and e-mail & Years of working (Any change after nomination may be informed immediately)

3. Address for Correspondence :

4. Date of Birth : Age: Years. Months ( As on 31st December 2014) (Enclose only one attested copy of the Birth Certificate)

5. Academic Qualifications (beginning with the Bachelor's Degree):

Degree Subject(s) University Year of award Class/rank

6. Present Occupation and Nature of Duties :

7. Awards and/or other recognitions received :

8. Field of Specialisation :

9. Research Experience :

10.( A) Statement of the specific research contributions : for which the award is recommended ( Maximum 500 words) ( Work done in Kerala institutions alone will be the basis for consideration for the award).

10.(B). A brief statement about the novelty of the work : (Not more than 50 words)

11. List of Publications :

(Information may be provided under these heads: a) Up to best 10 papers in the last 5 yearspublished in refereed journals. Manuscripts under preparation should not be mentioned.Reprints or photocopies of the publications should be included. 3 Most importantpublications should be tick-marked in the list).

Author/Authors(corresponding author/Authors should be marked with* )

Title Journal Volume, Page No. & year

Impact factor

12. Dated Signature of the nominee self-authenticating : the details above.

13. Subject Committee to which , in the opinion of the : proposers, the nomination should be referred to. Only one Subject Committee may be indicated.

14. Name, designation, signature and full address of : the proposer of the nomination.

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