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MAHARASHTRA IINIVERSITY
;*LY;, HEALTH OF SCIENCES, NASHIK
MUHS ffi-et te, qrtca,
q1ft55 - YRRo oY Dindori Road, Mhasrul, Nashik - 422004
Tel:( 0253 253917111691173/665917111691173 E Student Helpline:0253-25391 1 1/66591 111100
Website: www. muhs.ac.in E-mail uhs.ac.in
gr- Dr. Devendra Sheshrao Patil
qq.*.( dft*{ff) M.D. (Homoeopathy)
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 Annexure -'A'
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i,,lk i
I;.f; MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK
Application Format for Best Teacher Award 2024-25

1. Name ofThe Teacher:

with E-mail id & Mobile No.

2. Name of the College :

3. Educational Qualifications : (Starting from Degree course. Please attach attested photocopy of tvlarksheet)

Course University % of Marks Grade

Degree course

PG Degree

Additional Qualiflcation (Diploma after

P.G. / Fellowship/ Ph.D.

Awards / Medals at UG level

Awards I Medals at PG level

4. a. Experience Details : ( Please attach relevant attested photocopies of Experience Certificates.)

College / lnstitution Position Achievements with

From To
Held documen roof

b. University Approval as a teacher ( Please attach attested photocopy of approval letter) Yes i No
G. Ph.D Guide
d. Awards / ft/edals at State level for teaching purpose.
e. Awards / tvledals at National level for teaching purpose.
f. Awards / It/edals at International level for teaching purpose.:
(Please attach relevant attested photocopies of Certificates.)
g. Position held in any Professional associations
h. Positions held in any Non- Professional associations
i. Any Participations in National Health program
j. in policy development (University / central council / State council)
[ole
k. Role in lnnovations & Patents

Nature of Award / Medal Year of Award / Medal

5. Research Work : ( Please attach attested photocopy of Certificates.)
Subject of Project with lnnovations
Development of Teach i n g
Utility & Applications Tools
Description

6. Research Publication I

Publication of Research Material, (Please attach relevant proof/Certificates. i.e. photocopy of cover & ast
page ) :

a) Research Grant: > 2 Lakh Yes / No.

b) State / National/ lnternational Research Publication. Yes / No (Peer reviewed / Pubmed /
Scopus / Web of Sceinces)
(Details in short with the Title Name & relevant proof.)
c) Peer Reviewer at lnternational level Yes / No.
d) Editor of lndexed Journal Yes / No.
e) Text Book Publicatios / Any Subject related
f) Research Award (State / National / Local) Yes / No

7. Conferences :

A. Participation Reading of Research Paper in conferences : ( Please attach relevant proof/Certificates)

tCME Workshop / National Paper Presentation / lnternational Presentation)

Subject / Title of Date & State / National / Participation / As a Resource

Paper Venue lnternational level Convenor Person / Faculty

B. Member of Organising Team As Chairman / Organising Secretary / Member ( Please attach

relevant proof/Certificates)

Subject I Title of Date & State / National / Participation / As a Resource

Paper Venue lnternational level Convenor Person / Faculty

8. A) Author of Text (As a First Author) / Reference books :

( Please attach relevant proof/Certificates i.e. photocopy of cover & last page )

Please put tick in proper columns

Title of book Publisher Contribution in
Text Reference Book Contributory Author Editor
Online Modules

B) Author of Text (contributory Author) / Reference books :

( Please attach relevant proof/Certificates i.e. photocopy of cover & last page )

Please put tick in proper columns

Title of book Publisher Contribution in
Text Reference Book Contributory Author Editor Online Modules
 9. Non-Teaching Responsibilities & Other activities : ( Please attach relevant proof / Certificates.)

Participation As
Year of activ ity / details Achievements with docum
University appointed
Committee N/ember

University Authority [t/em ber

NSS Coordinator

10. Any Other lnformatio n which supports Your claim:

( Publication Patents / Design Patents / Copy rights ) ( Please attach relevant proof /
Certificates.

1 1. Whether the peer review report of 3 teachers & 2 students is enctosed in a sealed
envelope
and titled as peer review proforma - confidential on the envelope. yes/No
12' I solemnly declare that, the above furnished information is true and
correct to the best of my
knowledge.

Date :

( Signature of Applicant )
Place :

Note Please note that, Applications, which are not in prescribed format
/ lncomplete / without obtaining
signatures or those without necessary certificates shall be rejected.
 Annexure *'B'
r;i
S,,
uu-us
MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK

(Please use prescribed format only.)

1. Name of the Student :

with E-mail id & Mobile No.
2. Name of the College :

3. Academic Performance : (Performance of MUHS Exam. Please attach attested photocopy of

Marksheet)

I Year % of Marks llYear % of Marks lllYear % of Marks lV Year % of Marks

4. Academic Distinctions : (Please attach relevant attested photocopy of lVlark sheet / Certificates.)
a) Whether Student has been College Topper in last MUHS Examination? : Yes / No
b) Whether Student has been University Topper / Medallist in last Examination? : Yes / No

5. Research Activities: (Please attach relevant attested photocopy of Certificates.)

' ( Please attach Separate sheet giving details of Research Activities & Awards / Scholarships received.)
a) Whether Student has received Scholarship under Short Term Research Grant of University : Yes/ No
b) Whether Student has received Scholarship for research by other agencies. : Yes / No
c) Whether Student has received Award for Research.
Student has received Award for Research
1. State Level Award for Research Yes / No

2. National Level Award for Research Yes / No

d) Whether participated in Avishkar Research Festival University / lnter University level ?

Participated in Avishkar Research Festival
1. University level Yes / No

2. lnter University level Yes / No

e) Whether Ranked 1st I 2nd I 3'd at University level Avishkar Research Festival? : Yes/ No

0 Whether Ranked 1st I 2^d at State / National level Research Festival? Yes / No

6. Extra-Gurricular Activities: (Please attach relevant attested photocopy of Certificates.)

a) Whether a Student has participated in Zonal I lnter-Zonal / Ashwamedh /AlU Sports i Other Games

Name of Event Sports/Games played Year of Performance Awards / Medals received if any

University Zonal trials

lnter - Zonal Selection

Ashwamedh lKrida
J\Iahotsav

A I U Sports

State level Games

NationalGames
 b) Whether a Student has pa ated in lnter-Coll ei lnter-Unive / State Level Cultural Events
Name of Event Activities performed Year of Performance Awards / Medals received if any
Spandan

lndradhanushya

AIU / Youth Festival

Other State levels

Other National levels

c) Whether Participated in Avhan / Abhiyan ? Yes / No
1. Avhan - Disaster Management Yes / No

2. Abhiyan - a) Medical Camp.

b) Social organisation. Yes / No

7 Other Representations : (Please attach relevant attested photocopy of Certificates.)

a) Whether a Student is Elected as University Students' Council Member /University Senate
lr/ember / Office Bearer of University Students, Council.
(Please furnish the details in following Table & attach necessary proof.)

No. Position Class lYear No. of Times Remarks if any

a) Member - University Students Council

b) Member - Senate / Office bearer of

Un Students Council
b Whether a Student has rtici in NSS / NCC / Soci Oriented Activities details
No. Activity Class / Year Awards / Achievements if any
a) NSS activities with this University

b) NCC activities with this University

8. Publication : (Please attach relevant attested photocopy of Certificates.)

a) Medical Publications : yes / No.
b) Publication in Social Media : yes / No.
c) Publication in print Media : yes / No.

9' I solemnly declare that, the above information furnished is true and correct
to the best of my
knowledge.

( Signature of Appticant )
10. Signatures of concerned in-charges
(These signatures are must as to certify-these activities.)

Name & Signature of Name & Signature of

NCC / NSS Programme Officer l/C Sports Officer

Name & Signature of Name & Signature of Cultural ln charge

Research Head / Avishkar activity
11 Recommendations of Dean / principal: (please write add itional lnformation justifying
nomination.)
Certified that, I have personally checked the above info ati on / Certificates
& found them correct.
College
Seal
( Dean / Principal
Note : )
Please note that, App lications, which are not in prescribed format / lncomplete
/ without
obtaining Signatures or those without necessary certificates shall be rejected
 Annexure -'C'
/-::'-..
irTir:,il MAHARAS HTRA U N IVERS ITY OF HEALTH SCIENCES, NASHIK
"l?'
Application Format for Best Sport Student Award 2024-25
(Please use prescribed format only.)

1. Name of The Student :

2. Mobile / Landline No. :

3. E-mail id :

4. Name of The College :

5. Academic Performance : (Performance and preceding year of MUHS Exam. Please attach attested
photocopy of Marksheet)
oh of oh of ill o/o
ot IV %ot
I Year llYear
Marks Marks Year Marks Year Marks

6. Academic Merits / Research Activities: ( Please attach relevant attested photo copies of Mark sheet /
Certificates)
' a) Whether Student has received University (MUHS) Merit Certificate? : Yes / No
b) Whether Student has been University Topper i Medallist in last Examination ? : Yes / No
c) Whether Student has received Sport Merit Scholarship given by this University/others?:Yes/No

d) Whether participated in Avishkar Research Festival ? : Yes / No

e) WhetherwonAwardatAvishkarResearchFestival ?(l/lli lll ) : Yes / No

7. Extra-Curricular Activities: (Please attach relevant attested photocopy of Certificates.)

a) Whether a Student has been Elected as Sports Secretary/Cultural Secretary/General Secretary (GS)
Class /
Position / Membership Class / Year Position I Membership Year
1) rl
2) 4)

b) Whether a Student has participated in NSS / NCC I Volunteer (give details )

Awards I Achievements if
Activity Class & Year of Activity
any

NSS activities with this University

c) Whether a Student has parlicipated in lnter-College / lnter-University Cultural Activities / Events

Participation Year of Awards / Medals

Name of the Event
details Performance received

$pandan

lndradhanushya

Avhan / Abhiyan
 L Sports Performance :

Whether a Student has participated in various Level of Sports / Games. ( give

details )
( Please attach relevant attested photocopy of Certificates. Performance
li
shall not be counted if attested
Photo copies of Certificates are not encloied
)
a) University Level
Year of Awards /
Name of the Event Games Venue
Participation Medals
received
lnter-Zonal Round

Coaching Camp

1st Year

2nd Year (Participation two times)

Year (Participation three or
3rd
more times)
b) Ashwamedh/Krida Mahotsav
Ashwam edh/Krida Mahotsav - 1st
Year
Ashwam edh/Krida Mahotsav - 2nd
Year
As hwamedh/Krida Mahotsav - 3'd
Year
Ashwam edh/Krida [Mahotsav - 4th
Year
Ashwamedh lKrida lt4ahotsav - 2 or
more mes
c) All lndia lnter Univers itv
All lndia University - 1st Year
All lndia University - 2nd Year

All lndia University - 3d year

All lndia University - 4th Year

All lndia University -
2 or more ES
oth er Performance at State /
National

I ! solemnly declare that, the above furnished information is true

and correct to the best of my
knowledge .

Date :
Signature of Applicant

lame & Signature of Name & Signature of

Cultural Coordinator NSS programme Officer
10' Recommendations of Dean / Principal: (Please write additional lnformation justifying nomination.)
certified that, I have personatly checked the above information
i certificates & found them correct.

Name & Signature of College

ln-charge - Sports Seal

Signature of
Dean / Principal
Note Please note that, an application, which is not in prescribed
format / lncomplete / without Signatures
or without necessary certificates will be rejected.