IEEE Potential Nominee Form

Nomination for a Medal or Award does not require submission of this form.

1. Potential Candidate
Provide as much of the following on the potential nominee(s) as is readily available to you.

Last Name   First Name   Initial  

Business Affiliation  

Street Address:  

City   State   Country  

Postal Code  

Telephone Number   Email Address  

2. Medal or Award for which candidate should be considered.

Link to Awards Page

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

4. Form Submitted by

Last Name   First Name   Initial  

Business Affiliation  

Street Address:  

City   State   Country  

Postal Code  

Telephone Number   Email Address  

5. Are you willing to serve as nominator?   Yes   No

If proposal is for a group, provide information for other members below.