Department of Science & Technology
and Biotechnology, Government of West Bengal

Gopal Chandra Bhattacharya Smriti Puraskar

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01. Personal Details

Name of the Applicant *
Date Of Birth *
Gender *
Mobile no. *
Alternate Mobile no.
Email ID *
Alternate Email ID
Residential Address *
State *
District *
City / Town / Village *
P.O. *
P.S *
Pin code *
02.Professional Details

Organisation Type *
Name of the Organization *
Department/ Division *
Designation *
Address of the organization *
State *
District *
City / Town / Village *
P.O. *
P.S *
Pin code *
Telephone (office) *
Fax no. *
email ID *
website (if any) *
03. Achievement Proposed for Consideration of the Award
Broad area of activity: (please tick) *
Details of the work done(last 20 years) (in 500 Characters): *
Region benefited:*
Period of implementation
from *
To*
Funded by*
Target beneficiaries*
Approximate no. of beneficiaries*
Any specific section community served *
Impact of the project done: (in 200 Characters)*
Any other Recognition/Award received for the achievement mentioned:
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Award Name By Date
Future scope of expansion or replication: (in 200 Characters) *
Other awards received from the Government of West Bengal:
Satyendra Puraskar
Received Date
Applied Date
Nominated Date

Rabindra Puraskar
Received Date
Applied Date
Nominated Date

Vidyasagar Puraskar
Received Date
Applied Date
Nominated Date

Bankim Puraskar
Received Date
Applied Date
Nominated Date
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