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2011 IEEE MEMbErshIp ApplIcAtIon

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2011 IEEE MEMbErshIp ApplIcAtIon Powered By Docstoc
					2011 IEEE MEMbErshIp ApplIcAtIon
(students and graduate students must apply online)

Start your membership immediately: Join online www.ieee.org/join                                                        3       Please Tell Us About Yourself
Please complete both sides of this form, typing or printing in capital letters.                                       Select the numbered option that best describes yourself. This
Use only English characters and abbreviate only if more than 40 characters and                                        information is used by IEEE magazines to verify their annual circu-
spaces per line. We regret that incomplete applications cannot be processed.                                          lation. Please enter numbered selections in the boxes provided.
                                                                                                                     A. Primary line of business




                                                                                                                                                                                                    ▼
 1 PERSONAL INFORMATION
     Name & Contact Information                                                                                         1.   Computers
                                                                                                                        2.   Computer peripheral equipment
Please PRINT your name as you want it to appear on your membership card and IEEE                                        3.   Software
correspondence. As a key identifier for the IEEE database, circle your last/surname.                                    4.   Office and business machines
                                                                                                                        5.   Test, measurement and instrumentation equipment
Male ■               Female ■               Date of birth (Day/Month/Year)                                              6.   Communications systems and equipment
                                                                                           /         /                  7.   Navigation and guidance systems and equipment
                                                                                                                        8.   Consumer electronics/appliances
                                                                                                                        9.   Industrial equipment, controls and systems
Title     First/Given Name                 Middle                 Last/Family Surname                                  10.    ICs and microprocessors
                                                                                                                       11.    Semiconductors, components, sub-assemblies, materials and supplies
▼   Home Address                                                                                                       12.    Aircraft, missiles, space and ground support equipment
                                                                                                                       13.    Oceanography and support equipment
                                                                                                                       14.    Medical electronic equipment
Street Address                                                                                                         15.    OEM incorporating electronics in their end product (not elsewhere classified)
                                                                                                                       16.    Independent and university research, test and design laboratories and
                                                                                                                              consultants (not connected with a mfg. co.)
City                                                   State/Province                                                  17.    Government agencies and armed forces
                                                                                                                       18.    Companies using and/or incorporating any electronic products in their
                                                                                                                              manufacturing, processing, research or development activities
                                                                                                                       19.    Telecommunications services, telephone (including) cellular
Postal Code                                            Country                                                         20.    Broadcast services (TV, cable, radio)
                                                                                                                       21.    Transportation services (airline, railroad, etc.)
                                                                                                                       22.    Computer and communications and data processing services
Home Phone                                             Home E-mail                                                     23.    Power production, generation, transmission and distribution
                                                                                                                       24.    Other commercial users of electrical, electronic equipment and services
                                                                                                                              (not elsewhere classified)
                                                                                                                       25.    Distributor (reseller, wholesaler, retailer)
▼   Business Address                                                                                                   26.    University, college/other educational institutions, libraries
                                                                                                                       27.    Retired
                                                                                                                       28.    Other__________________________
Company Name                                           Department/Division
                                                                                                                     B. Principal job function




                                                                                                                                                                                                    ▼
Title/Position                                         Years in Position                 Years in Profession            1.   General and corporate management           9. Design/development
                                                                                                                        2.   Engineering management                        engineering - digital
                                                                                                                        3.   Project engineering management            10. Hardware engineering
Street Address                                         City                              State/Province                 4.   Research and development                  11. Software design/development
                                                                                                                             management                                12. Computer science
                                                                                                                        5.   Design engineering management             13. Science/physics/mathematics
Postal Code                                            Country                                                               - analog                                  14. Engineering (not elsewhere
                                                                                                                        6.   Design engineering management                 specified)
                                                                                                                             - digital                                 15. Marketing/sales/purchasing
                                                                                                                        7.   Research and development                  16. Consulting
Office Phone                                           Office Fax                        Office E-mail
                                                                                                                             engineering                               17. Education/teaching
                                                                                                                        8.   Design/development engineering            18. Retired
                                                                                                                             - analog                                  19. Other _____________________
Send all IEEE mail: ■ Home Address                        ■ Business Address
To better serve our members and supplement member dues, your postal mailing address is made available to             C. Principal responsibility




                                                                                                                                                                                                    ▼
carefully selected organizations, to provide you with information on technical services, continuing education, and
conferences. Your e-mail address is not rented by IEEE. Please check box only if you do not want to receive these       1.   Engineering and scientific management      6.   Education/teaching
postal mailings to the selected address. ■                                                                              2.   Management other than engineering          7.   Consulting
                                                                                                                        3.   Engineering design                         8.   Retired
                                                                                                                        4.   Engineering                                9.   Other _______________________
                                                                                                                        5.   Software: science/mngmnt/engineering
 2         Attestation
                                                                                                                     D. Title
                                                                                                                                                                                                    ▼
I have graduated from a three-to-five-year academic program with a university-level degree.
■ Yes      ■ No                                                                                                         1.   Chairman of the Board/President/CEO       10.   Design Engineering Manager
                                                                                                                        2.   Owner/Partner                             11.   Design Engineer
This program is in one of the following fields of study:                                                                3.   General Manager                           12.   Hardware Engineer
                                                                                                                        4.   VP Operations                             13.   Software Engineer
■    Engineering
                                                                                                                        5.   VP Engineering/Dir. Engineering           14.   Computer Scientist
■    Computer Sciences and Information Technologies                                                                     6.   Chief Engineer/Chief Scientist            15.   Dean/Professor/Instructor
■    Physical Sciences                                                                                                  7.   Engineering Management                    16.   Consultant
■    Biological and Medical Sciences                                                                                    8.   Scientific Management                     17.   Retired
■    Mathematics                                                                                                        9.   Member of Technical Staff                 18.   Other ______________________
■    Technical Communications, Education, Management, Law and Policy
■    Other (please specify): _________________                                                                       Are you now or were you ever a member of IEEE?
                                                                                                                     ■ Yes ■ No If yes, provide, if known:
This academic institution or program is accredited in the country where the institution
is located. ■ Yes     ■ No ■ Do not know                                                                             Membership Number                          Grade                        Year Expired

I have ______ years of professional experience in teaching, creating, developing,
practicing, or managing within the following field:                                                                    4          Please Sign Your Application
■    Engineering                                                                                                      I hereby apply for IEEE membership and agree to be governed by the
■    Computer Sciences and Information Technologies                                                                   IEEE Constitution, Bylaws and Code of Ethics. I understand that IEEE
■    Physical Sciences                                                                                                will communicate with me regarding my individual membership and all
■    Biological and Medical Sciences                                                                                  related benefits. Application must be signed.
■    Mathematics
■    Technical Communications, Education, Management, Law and Policy
■    Other (please specify): _________________
                                                                                                                      Signature                                                  Date
                                                                                                                                                                                                Over Please
  5       Add IEEE Society Memberships (Optional)                                                6         2011 IEEE Membership Rates
                                                                                                           (student rates available online)
The 38 IEEE Societies support your technical and professional interests.
Many society memberships include a personal subscription to the core                           IEEE member dues and regional assessments are based on where
journal, magazine or newsletter of that society. For a complete list of                        you live and when you apply. Membership is based on the calendar
everything included with your IEEE Society membership                                          year from 1 January through 31 December.
visit www.ieee.org/join.                                                                                                                                      BETWEEN             BETWEEN
                                                                                               Please check ✔ the appropriate box.                          16 AUG 2010-        1 MAR 2011-
                                                                                                                                                             28 FEB 2011        15 AUG 2011
Please check ✔ the appropriate box.                                  BETWEEN       BETWEEN                                                                       PAY                PAY
                                                                    16 AUG 2010- 1 MAR 2011-   RESIDENCE
                                                                    28 FEB 2011 15 AUG 2011
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                                                                                               Canada (includes GST)* .............................. $161.80 ■ ...........$80.90 ■
IEEE Aerospace and Electronic Systems z y                AES010       25.00 ■       12.50 ■
                                                                                               Canada (includes NB, NF and ON HST)* .... $172.68 ■ ...........$86.34 ■
IEEE Antennas and Propagation z y 	                      AP003        24.00 ■       12.00 ■
                                                                                               Canada (includes Nova Scotia HST)* .......... $175.40 ■ ...........$87.70 ■
IEEE Broadcast Technology § z y 	                        BT002        15.00 ■        7.50 ■
                                                                                               Canada (includes BC HST)* ........................ $171.32 ■ ...........$85.66 ■
IEEE Circuits and Systems z y §                          CAS004       18.00 ■        9.00 ■
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IEEE Communications z y                                  C0M019       25.00 ■       12.50 ■    Latin America .............................................. $140.00 ■ ...........$70.00 ■
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IEEE Electron Devices § z y                              ED015        12.00 ■        6.00 ■      7         More Recommended Options
IEEE Engineering in Medicine and Biology z y             EMB018       35.00 ■       17.50 ■
                                                                                               Proceedings of the IEEE ............ print $36.00 ■ or online $34.00 ■
IEEE Geoscience and Remote Sensing § y 	                 GRS029       18.00 ■        9.00 ■
                                                                                               Proceedings of the IEEE (print/online combination) .............$47.00 ■
IEEE Industrial Electronics z y 	                        IE013        15.00 ■        7.50 ■
                                                                                               IEEE Standards Association (IEEE-SA).................................$47.00 ■
IEEE Industry Applications z y                           IA034        20.00 ■       10.00 ■
                                                                                               IEEE Women in Engineering (WIE) .......................................$25.00 ■
IEEE Information Theory § z y                            IT012        30.00 ■       15.00 ■
IEEE Instrumentation and Measurement z y                 IM009        28.00 ■       14.00 ■      8         Payment Amount
IEEE Intelligent Transportation Systems § z y            ITSS O38     35.00 ■       17.50 ■
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IEEE Magnetics § y tz 	                                  MAG033       25.00 ■       12.50 ■
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IEEE Microwave Theory and Techniques z y                 MTT017       17.00 ■        8.50 ■
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IEEE Oceanic Engineering § z y                           OE022        19.00 ■        9.50 ■    IEEE-SA/WIE dues (optional) 7 ..................................... $ ______
IEEE Photonics § y 	                                     PHO036       30.00 ■       15.00 ■    Proceedings of the IEEE (optional) 7 ............................. $ ______
IEEE Power Electronics § y                               PEL035       20.00 ■       10.00 ■    Canadian residents pay 5% HST or appropriate HTS (BC12%, NB, NF,
                                                                                               ON-13%,NS-15%) on Society payments & publications only ............ TAX          $ ______
IEEE Power & Energy z y 	                                PE031        35.00 ■       17.50 ■
                                                                                               AmounT PAId ......................................................... ToTAL $ ______
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IEEE Reliability § z y 	                                 RL007        35.00 ■       17.50 ■    by credit card (see below), check or money order payable to IEEE,
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IEEE Signal Processing § z y
IEEE Social Implications of Technology § z y
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