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» Membership » MD » MD Programs » SM Program
Senior Member Reference Form

Print this Form and bring on Sat. Nov 16. to the IEEE Office. Please note that submitting this reference form does not by itself constitute a nomination. In order for the Section or Society to qualify for the NSI rebate of $10 per successful nomination, the nomination section of the SM Application Form must be filled in completely including the name of the nominating entity.

For any questions relating to the Senior Member application process, send your inquiry to senior-member@ieee.org

TO BE COMPLETED BY THE IEEE SENIOR MEMBER OR FELLOW SERVING AS REFERENCE
Name of Applicant:
Applicant's member number (if known)
A. Do you know the candidate professionally?
If yes, how long?	years
What is your professional relationship to the candidate?
B. Has the candidate been in active professional practice for at least 10 years?	Total years in the profession
C. In your own words, explain how the candidate has significantly performed his/her professional duties for at least five years. (Use as much space as you need)

D. Please indicate whether you consider the candidate to be:
INFORMATION ABOUT THE IEEE MEMBER SERVING AS REFERENCE
My Name:
My IEEE Membership Number (required) :
My IEEE Membership Grade:
Date:

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