Computer Society of IndiaTM

Education Directorate, National Headquarters

ED Award Form-9 Version 3.0
CIT Campus, IV Cross Road, Taramani, Chennai 600 113
Phone: 044-2254 1103 / 2874 Website: www.csi-india.org
email: edawards@csi-india.org

Scan
Passport size
Photo of the

candidate

Application for Highest Committed Student Branch Activist Award

(Awarded to the CSI Volunteer who was most active at CSI Student Branch during 01/07/2015 to 30/06/2016)

(To be filled up by Student Branch Counsellor)

1) Name of the CSI Volunteer being nominated by SBC: __________________________________
2) Name of the Institution: __________________________________________________________
3) Postal Address: ________________________________________________________________
____________________________________________________________________________
City: ________________________________________ PIN: ___________________________
State: _______________________________________
4) Phone No. ____________________ Email ID: ______________________________________
5) Candidate (CSI Volunteer) Email ID: ______________________________________________
6) Institution Membership No: ______________ Valid till: ________________________________
7) Number of CSI Volunteers as on 30

th

June 2016:

_____________

8) Number of CSI Volunteers added during July 2016 June 2017: _____________
9) Nominated CSI Volunteers ID: _____________ Valid till: _____________
10) Sponsoring SBC details:
SBC Name: _________________________ Designation: ____________________________
Email ID: ___________________________ Mobile No: ____________________________
11) Event details:
Sl No

Event name

Event held at
which Place

Role played Paper Presenter /

Competitor / Speaker / Other
(specify) & topic chosen

1
2
3

(Table may be extended as required. Attach copies of event brochure / invitation, photos taken at
the events etc)
Declaration
We declare that the above statements are true to the best of our knowledge and belief. If anything is found
wrong / incorrect, we understand our application is liable for rejection.
Place:
Date:
Signature of Head of the Institution with Seal

Relevant documents & completed application are to be sent to edawards@csi-india.org on

th
or before 7 October 2016 with the subject of the mail as Academic Awards 2016.