Nomination Form (Pioneer Research Award)

Nomination By ^* :

Self

Others

Nominee Name ^* :

Nominee Organization ^* :

Nominee Mail ID ^* :

Address ^* :

City ^* :

State ^* :

Mobile no ^* :

Specialization/Field of work ^* :

Date of Birth ^* :

Total Experience in Years ^* : (After Graduation)

Brief Bio in Pursuit of Research ^* : (Maximum 400 words)

Please upload your CV on Google Drive and Paste link here

Nominator Name ^* :

Number of Publications (Only Indexed Journals):

National (Indian Citizen): ^*

International:(Optional)

Average Impact Factor Of All Publications: ^*

Number of Citations: ^*

H Index ^* :

Number of Books/Chapters authored by you:

Number of Patents Awarded to you:

Number of Abstracts published in Indexed Journals ^* :

Number of Publications in Indexed Journals as First/Corresponding Author ^*:

Number of Publications as Other than First/Corresponding Author:

Answer the following Questions:-

1. Mention your best research/s according to you (maximum of 3) ^* : (Maximum 250 words)

2.What according to you is the future road map of research/s undertaken by you? ^* : (Maximum 250 words)

3. Describe the Clinical Utility/ Impact and Applicability of the Research contribution made by you ^* : (Maximum 250 words)

4. What are the Public Health Implication of research/s made by you? ^* : (Maximum 250 words)

5. What makes you the best candidate for this award? ^* : (Maximum 250 words)

6. Mention previous awards and honours, if any ^* : (Maximum 250 words)

Notes:-

1) Applicant is advised to fill the form in word document with all details including answers to the questions and paste them in the form in one go (as right now form is not having option for save and resume)
2) Application money of ₹15,000 plus taxes is to be paid after submission of this form.
3) Applicable only to individuals 45 years and above of age.
4) Fields marked * are mandatory. Rest of the fields are optional, however information provided by you will help us in better evaluation of your nomination.

Declaration:-

The information provided herein is true and complete to the best of my/our knowledge. Some of the information provided in the document could be sensitive and shall remain confidential unless I/we agree to release it. I/We understand that the information provided in this document will be used by the organizers and the jury in deciding the awards and I/We consent to the use of this information for such a purpose. I/We further agree that this information may be used for further research, education, or any other purpose as long as the company details or not divulged to any person other than the organizers. If I am shortlisted/selected for receiving the award, I hereby authorize the use, in connection with the “Second edition of the Blackbuck Medical Research Awards” program, of my name, my company’s (or organization’s) name, non-financial information, photographs, video or audio recordings of me from whatever source. I agree that no compensation shall be due to me or my company for such usage.

I hereby declare that I have read the Declaration for nomination and understood it clearly.

Nomination Form (Pioneer Researcher Award) (For Ages 45 Year And Above Only)

Nomination Form (Pioneer Researcher Award)
(For Ages 45 Year And Above Only)