Nirma University

Institute of Technology
Foundation Day Celebrations
Nomination for Felicitation

Student: B Tech M Tech MCA Faculty member/staff:

Academic Year: (2019-20 / 2020-21)

(Please tick the appropriate)

Name (in BLOCK Letters) : ___________________________________

Father’s Name (in BLOCK Letters)
Roll No ( if applicable)
Full Residential Address
[for invitation to the parents]
M:
Phone :
Branch
Semester
Details of Achievement / Specific
Contribution ( please attach the
copy of proof / certificate)
: ___________________________________
: ___________________________________
: ___________________________________
___________________________________
_________________R:________________
: ___________________________________
: ___________________________________
___________________________________
: ___________________________________
___________________________________

State Level National Level International Level

Year & Month of Achievement : ___________________________________

In case of Best paper publication /
: ___________________________________
presentation (Title of the paper)
Name of Journal / Conference : ___________________________________

Any Other details : ___________________________________

Signature of Applicant Signature of Signature of

Branch Coordinator Head

Note: Looking at the shortage of time, please submit the form with proof before 27 th September,
2021 (Saturday)