The ORISSA SOCIETY OF THE AMERICAS

 

Nomination Form for OSA Awards

 

Please Note:

The last date of Nomination is: April 30, 2008

Please refer to Award Guidelines for additional information. You are advised to send your nominations by email Dr. Birendra Jena at abjena@yahoo.com and for those awards requiring documentary proofs (such as Subrina Biswal Memorial Award), please send those documents by US/Canada mail to 175 Apple Grove St. NE #A-12, North Canton, OH 44720, USA.

 

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Nomination for (Please Circle One)

 

A.       Distinguished Oriya Award    

B.       Kalashree Award

C.       Utkala Mani Gopabandhu Das Memorial Award

D.       Youth Volunteer Award

E.        Yuva Kala Vikash Award

F.       Subrina Biswal Award

 

 Nominee Profile:

 

1          Name:

Address:                                              Phone

                                                                         Fax

                                                                        E-mail:

2.                  2.                  Age on July 1, 2008: (Applicable to Youth Volunteer and Yuva Kala Vikash Awards only):

3.                  3.                  A Brief Rationale for Nomination: (Please attach additional sheets if necessary) 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.         Nominee’s Association with OSA

 

(i)         Membership Status: Annual Member____Life Member_____Patron_____             Benefactor_____                                                                         

(In case of youth member, please indicate membership status of the parents)

(ii)        Association/ Involvement with the OSA Activities at both national and chapter level: (please specify)

 

(iii)       Attendance and participation in OSA Conventions:

 

5.         Accomplishments: (Please attach additional sheets if necessary)

(i)         Academic

 

 

 

 

 

 

(ii)        Research/publications /books/films etc.

 

 

 

(iii)       Literature (Oriya)

 

 

 

(iv)       Cultural (Oriya)

 

 

 

(v)        Heritage of Orissa

 

 

 

(vi)       Humanitarian activities

 

 

 

 

 

(vii)      Other related works for Orissa, the land and its people:

 

 

 

 

 

 

 

Referees:( Please provide names of THREE Referees who may be contacted by the judging committee if necessary)

 

1.         Name:

Telephone No./Fax No./Email address

 

2.         Name:

Telephone No./Fax No./Email address

 

3.         Name:

Telephone No./Fax No./Email address

 

 

Nominator Profile:
 Nominator’s Name:

 Address                                                         

 

 

 

Phone:

Fax:

Email:

Membership Status: Annual Member______ Life Member______   Patron_____        Benefactor_____

 

How many years have you known the Nominee?

Are you related to the Nominee?  Yes____   No_____

If yes, state relationship

 

 

 

 

Signature of the Nominator:

Date: