1. IEEE Membership DetailsIEEE Membership Number *Current IEEE Member or should have been an IEEE Member for a duration of 1 year at least within the previous 3 years from the year of application.Member since - Month *JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberMonthMember since - Year *2021202020192018201720162015201420132012201120102009200820072006200520042003200220012000Year2. Personal DetailsName of Nominee (as per 10th certificate) *Address for correspondence *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijan)BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta and MelillaChad ChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo (DRC)Congo (Republic)Cook IslandsCosta RicaCôte d’IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmark (Danmark)Diego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial Guinea EritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong Kong)HungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstan)KenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedonia (FYROM)MadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritius)MayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin Saint Pierre and MiquelonSamoaSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. Vincent & GrenadinesSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweCountryEmail *EmailConfirm EmailPhone *3. NationalityCountry *AfghanistanBangladeshBhutanIndiaNepalPakistanSri Lanka The MaldivesDocument *PassportVoter's IdPANDriver LicenceOtherAttach Here *4. Educationa. XX Board *X CGPA/Percentage *b. XIIXII Board *XII CGPA/Percentage *If applicant has pursued Diploma after X then please entre the aggregate percentage of all 3 yearsc. Undergraduate DegreeName of the Degree *Name of the College *Name of the University *Passing Year *202220212020Marks of First Year (Consolidated CGPA / Percentage) *Marks of Second Year (Consolidated CGPA / Percentage) *Third Year Exam Conducted *YesNoMarks of Third Year (Consolidated CGPA / Percentage) *Fourth Year Exam Conducted *YesNoMarks of Fourth Year (Consolidated CGPA / Percentage) *Due to Covid-19 Pandemic, if your University / Institute has not conducted the V / VII Semester exam or hasn’t declared the results for the said semester, you are requested to please submit marksheet up to the previous semester ONLY. Please send a mail to info@hfrc-ieee.org informing us about the status of your V or VII semester examination.5. Co-curricular/Extra-curricular AchievementsCo-curricular Achievements – Please list down your top achievements in the last 4 years (maximum 5) *Extra - curricular Achievements – Please list down your top achievements in the last 4 years (maximum 5) *6. ResearchTotal Number of Research Published *Details *Patents *7. Contributions towards College / University / Community / Society / Nation Towards Technical Development (in about 150 words) *Towards Social/Economic Development (in about 150 words) *Awards/ Recognitions Received *8. Recommendation 1Name of person recommending *His/Her Designation *Organization where he/she works *His / her contact number *His / her email id *Recommendation Letter (Scanned Copy) Max File Size : 200 KBRecommendation letters can also be mailed directly by the Referee to info@hfrc-ieee.orgTick box to state that we can contact the person for verification *I agree9. Recommendation 2Name of person recommending *His/Her Designation *Organization where he/she works *His / her contact number *His / her email id *Recommendation Letter (Scanned Copy)Max File Size : 200 KBRecommendation letters can also be mailed directly by the Reference to info@hfrc-ieee.orgTick box to state that we can contact the person for verification *I agreeStatement of Worthiness & include how the prize money would be used (250 words) *Please upload certificates / credentials that validate your academic, co-curricular and extra curricular achievements. The files can be in jpg / pdf format only. Recommendation letters / experience certificates or any other content which is in MS word file, may be scanned and converted to jpg/pdf and then uploaded. Each file being attached should not be more than 200 KB.X Class / Equivalent mark sheet * XII Class mark sheet (or equivalent level) *First Year Graduation *Second Year Graduation *Third Year Graduation Fourth Year GraduationAny Additional CertificatesAny Additional CertificatesAny Additional CertificatesAny Additional CertificatesIf any additional file / credential needs to be shared with the Award committee, please mail it to info@www.hfrc-ieeeawards.org Declaration: I hereby declare that the particulars furnished by me in this nomination / application form are true and correct to the best of my knowledge and belief. In case any information is found to be incorrect / false, my candidature shall be liable to be rejected.I AgreeSubmit