Indian association for the advancement of veterinary



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NOMINATION FORM FOR FELLOWSHIP OF IAAVR

Instruction: Please go through the enclosed Yellow Score Card and then fill up the nomination form. After completion of the nomination form, complete your score card (self assessment) and attach with this nomination form
1. Name (Full Capital Letters) :___________________________________________________

2. Father’s Name :___________________________________________________

3. Date of Birth :

Age as on 31.12.2008 :___________________________________________________

4. Permanent Address :___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

5. Correspondence Address

if different from No.4 ::___________________________________________________
6. Telephone nos :

STDCode____________ (O)__________®______________________Mb_______________________


E-mail:______________________________________________________________________________

7. Qualification [Attach a Xerox copy of degree certificate]

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Sl. No. Degree University/Institution Year Ran/Div/OGPA

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

1. BVSc &AH

2. MSc

3. MVSc


4. PhD

5. DSc


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8. Experience: Scale of Pay [Choose the present Scale]

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Sl. Scale of Pay with experience Experience Total No. From To years of

experience

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1. Rs.8000-10000 or equivalent with 5 yrs

experience

2. Rs.10000-12000 or equivalent with 5 yrs

experience

3. Rs.12000-18000 or equivalent with 5

yrs experience

4. Rs. 16400-22400 or equivalent with 5 yrs

experience

5. Rs. 16400-22400 or equivalent or above scale

with 10 yrs experience

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4. Awards [Attach Xerox copy of award certificate]

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Sl. No. Name of Award Awarding Agency Year of Award

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

1.


2

3

4.



5.

6.


7.

8.


9.

10


11.

12.


13.

14.


15.

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5. Fellowships [ Attach certificate of conferred fellowships]

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Sl. No. Name of Award Awarding Agency Year of Award

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1. FNAVSc

2 FNAASc

3 FNASc

4. FASc


5. FNA

6. Society Fellowship

7. Society Fellowship

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6. Foreign Visit [Choose and Tick only one Visit] (Attach evidence)

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Sl. No. Foreign visit Tick appropriate

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1. Foreign visit upto 3 months

2. Foreign visit upto 6 months

3. Foreign visit upto 9 months

4. Foreign visit upto 12 months

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7. National Fellowships [Tick appropriate Fellowships] (Attach evidence)

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Sl. No. National Fellowships Tick appropriate

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––


1. INSA Visiting Scientist Fellowship 3 months

2. DST SERC Visiting Fellowship 3 months


8. Administrative Experience (Attach evidence) [Tick the one experience of highest position)

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Sl. No. Administrative Exerience Tick appropriate

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

1. Dean or Associate Dean

2. Vice Chancellor

3. Director of National ICAR Institutes/DDG

4. Animal Husbandry Commissioner

5. Director of ICAR Institutes

6. Advisor to Govt. Deptt

7. ADG ICAR or PD ICAR or JD National Insttt or Dean PG

8. Director State Govt AH Deptt

9. Head of National ICAR Insttt or Head of University levels

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9. Research Publications 10 Top with weightage of not less than 2.5 assigned by NAAS

Attach list of Publications as Annexure-I

10. Other Research Publications maximum list of 50- Annexure-II

11. Office bearer of societies etc [One time claim for one item] (Tick one) [Attach Proof]

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Sl. No. Officer bearer Tick appropriate

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1. President/Vice-President of Society

2. Secretary/Joint-Secretary

3. Treasurer

4. Member Executive Commitee

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12. Office bearer of journals etc [One time claim for one item] (Tick one) [Attach Proof]

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Sl. No. Officer bearer Tick appropriate

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1. Founder Editor/Chief Editor/Editor

2. Associate Editor/Co-editor

3. Member editorial board

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13. Popular and Technical Papers maximum 50- Attach list-Annexure-III

14. Books

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Sl. No. Title of Book authored with name of authors Year of Publication; Name of Publisher

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

1.


2.

3


Title of Book edited, name of editors Year of Publication, Publisher

1.


2.

3.


4.

5.
Chapter to books only. Title of chapters, authors Year of publication, Name of book published

1.

2.


3.

4.


5.

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15. PATENTS [Attach Proof]

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Sl. No. Title of Patent Year of Patent

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

1.

2.


3

4.


5.

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16. TECHNOLOGIES DEVELOPED (Attach Proof)

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Sl. No. Details of Technology Year of Commercialization

of Technology

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

1.


2.

3

4.



5.

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17. Radio Talks Maximum 10 items-Attach a list Annexure-IV

18. Students Guidance

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Sl. No. Title of Thesis & Year Name of Student Subject/Discipline

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MVSc


1.

2.


3.

4.


5.

PhD


1.

2.


3.

4.


5

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19. Extramural funding project awarded by DBT/ICAR/ICMR/CSIR or any other agency

[Claim one Project] Refer Score Card

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Sl. No. Title of Project PI or Awarding Year of Cost of Co-PI agency Award Project

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20. Life Membership of IAAVR : Yes/ No

21. Participation in IAAVR Conferences

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Sl. No. Details of Participation in IAAVR Conference Year of Participation

Attach Participation Certificate

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1. . 3. 4. 5. ––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

22. Contribution to IAAVR or other Societies

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Sl. No. Details of Contribution Year

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1. Organizing Secretary, IAAVR Conference

2. Joint-Organizing Secretary, IAAVR Conference

3. Organizing or Co-organizing Secretary, other Societies

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23. Details of Participation in two (outside India) International/Foreign

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Seminar/Conferences attended within last 10 years (Attach Participation certificate)

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1.

2.



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24. Overall assessment marks to be given by IAAVR
Note: Attach a copy of Full bio-data

Date: Signature of Candidate








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