(Kindly write/fill-up in CAPITAL LETTERS and/or select & tick [ √ ] your reply, whichever is applicable):
[Please do not leave any question unanswered/blank]
* * * *
PERSONAL BACKGROUND
* * * *
1. Name:
2. Date of Birth:
Prefix _________ Please select one of the following
(Dr./Dr.(Mrs.)/Dr.(Ms)/Prof./Prof.(Mrs.)/Prof.(Ms)/Mr./Mrs./ Ms.)
First Name _____________________________________
Middle Name _____________________________________
Last Name _____________________________________
DD____ MM____YYYY_____ Age as on 01.01.2013 ____Years
3. Sex [1] Male [2] Female
4. Communication Address: _________________________________________________
_________________________________________________
_________________________________________________
City___________ PIN__________ State_________________
5. Tel. No.(with STD code) _______________Mobile No. +91 _______________
6. Email ID. ____________________________ Fax No.(with STD code)__________
7. Languages Known: _________ _________ _________ _________ _________
8. Career/Work Experience inclusive of all the fields: ______ Years.
8 a). Specific Work Experience in Science Communication tasks: ______ Years.
[ √ ] your time involvement as Science Communicator: 8 b). Please indicate
Full Time [ ] Part Time [ ] Once-in-a-while: Please specify________________
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8 c) Indicate your Specialization related to Science Communication:
You can [ √ ] tick more than one:
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Agriculture Extension
Communication technology
Digital Media
Environment Communication
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Health Communication [ ]
Internet [ ]
Journalism
Newspaper
Popular Science Magazine
Science Fiction
Science Museums
Public Relations & Communications
Radio
Research in Science Communication
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Science Policy
Science Writing
Technical writing
Television
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Video [ ]
Any other – Please specify: _______________________________
9. Total No. of Projects undertaken in the field of Science Communication
indicating the language in which written:
[Give break-up hereunder]:
Language(s)_____ _____ _____ _____ _____ No(s) _______
No(s) _______
No(s) _______
No(s) _______
Language(s)_____ _____ _____ _____ _____
Language(s)_____ _____ _____ _____ _____
Language(s)_____ _____ _____ _____ _____
No(s) _______ Language(s)_____ _____ _____ _____ _____
[Give break-up of above Projects hereunder]:
9.1 a) As a Project Leader/Principal Investigator: Completed Nos. __________
b) As a Co-Investigator/Research Associate: Completed Nos. __________
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c) Mention below maximum important 5 Projects during last 5 years, indicating the Project
Title, the Year in which completed, Name of Funding Agency and Name of the Journal & its
Issue No., if published.
Projects: Completed
Project Title
(Max. 250 characters)
Year of
Completion
Funding Agency
(Max. 250 characters)
Journal Name &
Issue No.
(Max. 100 characters)
Projects: Ongoing
9.2 a) As a Project Leader/Principal Investigator: Ongoing _____________ No(s)
b) As a Co-Investigator/Research Associate: Ongoing _____________ No(s)
c) Title(s) of Ongoing Project(s) & Name of Funding Agency (Maximum 5):
Ongoing Project
(Max. 250 characters)
Funding Agency
(Max. 250 characters)
Language
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10. a) Total No. of articles, reviews, reports & books etc., published on innovative concepts in
the field of Science Communication indicating the language in which written:
National International
Language(s) Language(s) Publication
(Nos)
Publication
(Nos) b) Please mention below maximum important 5 publications during last 5 years:
Title
(Max. 250 characters)
Science Journal/
Newspaper
(Max. 100 characters)
National/
International
Issue No.
DD/MM/YY
(Max. 100 characters) c) Please mention below popular Lectures, Radio Talks, T.V. Programmes, Demonstrations and Training Programmes conducted in Science Communication, of latest 5 years:
(Max. 250 characters)
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d) Please mention below Papers on science popularization/communication not published in
Science Journals but submitted in Conferences, Seminars, Symposiums:
(Max. 250 characters)
ACADEMIC BACKGROUND
11. Educational Background:
Please specify hereunder highest degree obtained:
Qualification
(Max. 100 characters)
University/
Institution
(Max. 100 characters)
Year Subject(s)/ Area(s)/Field of
Study
(Max. 100 characters)
Please specify hereunder additional qualification, such as diploma if any:
Qualification
(Max. 100 characters)
University/
Institution
(Max. 100 characters)
Year Subject(s)/ Area(s)/Field of
Study
(Max. 100 characters)
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CAREER PROFILE
12. Kindly furnish below information about your employment/assignments related to
science communication tasks/activities carried out from present to preceding 5
years of your career (in descending order):
From To
DD/MM/YYYY
Designation/
Post held
Name & Address of
Employer*
(Max. 250 characters)
On Job assignments in
Science Popularization/
Communication (Mention
Nature of work in brief)
(Max. 250 characters)
*Please indicate: Central Government/State Government/Public Sector Undertaking/Private SectorCompany/
Autonomous Institution/Media Centre/NGO/Proprietorship Firm/Any Other, after the name & address of the
Employer.
13.
Awards & Achievements in science popularization tasks/activities
(National & International):
Name of Award(s)/
Achievements
(Max. 100 characters)
Awarding Organization(s)
(Max. 100 characters)
Year National /
International
14. Please state name(s) of Special Task Committees/Committees related to Science
Communication on which you have served and/or now associated:(Maximum 5):
(Max. 100 characters)
1.____________________________________________________________________
2.____________________________________________________________________
3.____________________________________________________________________
4.____________________________________________________________________
5.____________________________________________________________________
Please attach additional sheet, wherever necessary.
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