Nomination Form (Outstanding Research Institution Award)

Name of Organization ^* :

Type of Organization ^* :

Name of the Division/Department (if any) :

Name of Representative/Applicant ^* :

Designation of Representative/Applicant ^* :

Mail ID ^* :

Enter Your Correspondence Address ^* :

City ^* :

State ^* :

Mobile no ^* : +91

Number of Medical Staff involved in Medical Research:

Number of Medical Staff involved in Medical Research in India: ^*

Number of Research Projects undertaken in last 5 years:

Number of Research Projects undertaken in last 5 years in India: ^*

Number of Research/s Published in last 5 years: ^*

Number of Publications in Indexed Journals in last 5 years: ^*

Number of Citations: ^*

Answer the following Questions:-

1. Describe the Clinical Utility/ Impact and Applicability of the Research contribution made by your Organization ^* : (Maximum 250 Words)

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

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

4. What makes your Organization the best candidate for this award? ^* : (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 ₹18,750 plus taxes (Till 15 May) is to be paid after submission of this form.
3) 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.