Appendix I

Fellowship Award – Nomination Form

Name of the Nominee :
(in Block Letters)

IPA Membership No. :
Date of Joining :
Member for years :
Address of the Nominee :

Name of the Nominator :

IPA Membership No. :
Date of Joining
Member for years
Address of the Nominator :

Name of the 1st Supporter :

IPA Membership No. :
Member for years

Name of the 2nd Supporter :

IPA Membership No. :
Member for years


Information about the Nominee

Educational Qualification :

Highest Position held :

Name and address of Organization / Institution

Outstanding contributions in any of the field of Pharmacy namely Research, Education, Community Pharmacy, Hospital Pharmacy, Clinical Pharmacy, Drug Management, Regulatory control, Industrial Pharmacy etc. :

Served as an Office Bearer on the Central Council or State / Local Council or Divisional Committee of the IPA. ( e.g. President, Vice- President, Hon. Gen. Secretary, Treasurer, Editors of IPA publications or a member of the Executive Council of IPA at Central or at State / Local Branch level for at least four years.) :

Delegate or representative of the IPA on any Government Statutory Body / Committee, or fraternal organizations such as IPCA, PCI, DTAB, etc.:

Actively participated as an Office Bearer either in holding Annual Pharmaceutical Congress, Sessions, Conventions, Seminars, Symposia, Workshops, Exhibitions, Training programs organized by the IPA, or in association with fraternal international organizations like CPA, FAPA, FIP, PDA, AAPS, WHO etc. :

Served as Convener, Chairman, and Faculty member at programs organized by IPA or its Divisions. :

Note : You may add justification on one A4 size paper using font size not less than 12.
Attached : Yes / No

	Nominator	1st Supporter	2nd Supporter
Name
Signature
Place
Date