INDIAN INSTITUTE OF CHEMICAL ENGINEERS

DR.H.L.ROY BUILDING, RAJA S.C.MULLICK ROAD

KOLKATA 700 032

Tel: (033) 2414-6670 Email : iichehq@gmail.com

(Application Form for Acharya P C Ray Awards And Ambuja’s Best

Design Project Report Awards

1. Name of the candidate:

2. Membership Number of IIChE:

3. Address in full:

Present Permanent

E-mail: E-mail:
Tel.No. Tel.No.

4. Date of Birth:

5.A. Academic Record (Other than Chemical Engineering):

Date of Date of Name & address Certificate/Diploma/Degre

entry leaving of e obtained and
School/College Class/division

5.B. Academic Record (Chemical Engineering):

Date of Date of Name & address Degree and Class

entry leaving of obtained
College/University
6. Prizes and awards:
(Give details of any prizes, awards, scholarships and medals received
mentioning the related examination)

7. Other accomplishments – games and sports, elocution, dramatics:

(Give particulars of those, which are of outstanding merit)

8. Experience :
(Give details of any apprenticeship/employment in factories, research
institutes, etc.)

9. Project Report on Plant Design:

a) Subject ; ……………………………………………………………………….

b) Marks obtained …………………….out of ………………………………….

Place:

Date:

Signature of Applicant

Remarks by the Head of the Chemical Engineering Department

I have verified the above details and found them to be correct. I have to offer
additional remarks and recommendations as follows:

Place:

Head, Department of Chemical Engineering

………………………………………………………………

…………………..…………………………………………

NB: Last date of submission: 17th July 2020

Students must have membership of the Institute