DISTINGUISHED ALUMNUS AWARD 2013

NOMNATION FORM

1. Nominee’s Name (to be filled in block letters):

2. College Hindustan College of Science & Technology Hindustan Institute of Technology & Management Anand Engineering College Anand College of Pharmacy

3. Course & Branch B.Tech (Mention your Branch) B.Pharma MBA MCA BBA BCA

4. Batch

5. E-

mail

6. Mobile No.

7. Category of Nomination: Academic Excellence Professional Excellence Technology & Innovation Excellence Entrepreneurial Excellence Excellence in other walks of life

Year of commencementYear of passing

8. Achievements in the category of nomination (Please enclose additional sheets, if required)

9. Professional Experience(Please enclose additional sheets, if required)

10. Contribution that merits the award(Please enclose additional sheets, if required)

11. Any other relevant information

12. Brief Curriculum Vitae/ Resume of the Nominee enclosed Yes No

________________________________________________________________________________________

Proposed by (nomination may be done by self also)………………………………………………………….. If the proposer is an alumnus please give the details (College, Course, Discipline, Year of

Passing etc.)……………………………………………………………………………………………………………………….. Address: …………………………………………………………………………………………………………………………….. E-mail: ………………………………………………………………………………………………………………………………. Mobile No: …………………………………………………………………………………………………………………………

Date: Signature of Proposer:

Place: