NAME: ____________________________________   IEEE #: ____________

ADDRESS: ________________________________________________________

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1.  Award Category for which Candidate is Being Nominated
    (Please check only one category)
 ___ 1A. New Technical Concepts in Electrical Engineering
 ___ 1B. Electrical Engineering Professionalism
 ___ 1C. Promotion of Self-Development for Practicing Electrical Engineers
 ___ 1D. Enhancement of IEEE in Industry and Community Service
 ___ 1E. Electrical Engineering Management
 ___ 1F. Electrical Engineering Support for Student Activities
 ___ 1G. The William Terry Distinguished Lifetime Service Award

2. Achievements pertinent to the nominee's qualification for the 
Region 1 Award selected above. (Limit copy to space provided. 
List significant contributions related to Category selected. One-page, 
one-side only. Resume acceptable if advantageous to candidate.)
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3. Publications and Patents  
(Limit publications to subjects related to Category. Provide number, title, 
and date for any patents. Please use lines under items 5 and 6, if available, 
if additional space is required. Nominations will be returned without being 
reviewed if documentation is not provided.) 
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4. College Education and Degrees  (Designate honorary degrees with an "H".)
Degrees Received        Institution                    Date
__________________  ________________________________  ____________
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5. IEEE Units and Other Professional Organizations
Society/Organization    Office                         Grade
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6.  Honors and Awards
Award or Honor           Organization                  Date
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7.  Suggested Wording for the Citation:
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8.  Names of Three Endorsers  (Letters of Endorsement must be attached.)
    Name: _______________________________________ IEEE #: _________

    Address: ______________________________________________________

    Telephone #: ______________________ Fax #: _______________________

    Name: _______________________________________ IEEE #: _________

    Address: ______________________________________________________

    Telephone #: ______________________ Fax #: _______________________

    Name: _______________________________________ IEEE #: _________

    Address: ______________________________________________________

    Telephone #: ______________________ Fax #: _______________________

9.  Nominator or Sponsor
    Name: _______________________________________ IEEE #: _________

    Address: ______________________________________________________

    Telephone #: ______________________ Fax #: _______________________

    Position or Title:  ________________________________________________

    EMAIL: _______________________________________________________

    Signature:  ______________________________________  Date: _________