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THE INSTITUTE OF ELECTRICAL AND ELECTRONICS ENGINEERS_ INC_6_

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THE INSTITUTE OF ELECTRICAL AND ELECTRONICS ENGINEERS_ INC_6_ Powered By Docstoc
					THE INSTITUTE OF ELECTRICAL AND ELECTRONICS ENGINEERS, INC. IEEE Potential Nominee Form 1. Provide as much of the following on the potential nominee(s) as is readily available to you. If proposal is for a group, provide information for other members at the bottom of this form, in the section labeled, “Additional Information”.

Last Name:

First Name:

Initial

Business Affiliation: Street Address: City: State: Postal Code: Country:

Telephone Number:

E-mail Address:

2. Please name the Medal or Award for which candidate should be considered. You may read descriptions of the different medals and awards given by the IEEE on the Awards Page.

3. In less than 200 words, summarize the contribution(s) that you believe warrant this potential nomination.

Do not exceed space provided. Attached pages are not permitted. Type no smaller than 10 point.

REV. 12/07

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4.

Potential Nominee Form Submitted by:

Last Name:

First Name:

Initial

Business Affiliation: Street Address: City: Postal Code: State: Country:

Telephone Number:

E-mail Address:

5.

Are you willing to serve as nominator?

Yes

No

6.

Additional Information:

NOTE: The IEEE Awards Board reserves the right to consider any nomination for Institute Awards other than the award suggested when, in its judgment, the support and justification may more appropriately apply to other Institute Awards. Date: Signature:

Submit to: IEEE Awards Activities, 445 Hoes Lane, Piscataway, NJ 08854 Tel: 732.562.3844; Fax:732 981 9019; E-mail: awards@ieee.org

Do not exceed space provided. Attached pages are not permitted. Type no smaller than 10 point.

REV. 12/07

2


				
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