IEEE Canada
Online Industry Leadership Award Nomination Form - DRAFT

This form is to be used for the Industry Leadership Award.   You may submit more than one nomination but must complete a separate form for each one.   Each nomination form submission must be accompanied by separate forms submitted by each of the two endorsers you have named in parts 3 and 4.  

Do not send any additional material unless requested by the Awards Committee - resumes are NOT to be submitted.

Please read the information about these awards available on this web site before completing this form. It is recommended that you create all your content in a text editor and save for future use and as a personal record, then cut and paste into the form.   The maximum number of characters (including any spaces) for each entry is specified by a number beside the entry field and can not be exceeded. Complete all sections of this form and submit using the button at the bottom of this form.   Incomplete forms will not be considered.   If sections of this form denoted by * are not completed, you will not be able to submit your nomination.   The email address you enter in part 5 will be used by the IEEE Canada Awards Committee to respond to your nomination.  

If you have questions regarding the information required for any section of this form, please contact the IEEE Canada Awards Committee by email at awards@ieee.ca.




1. Select the Award             Submission date*  

There in one industry leadership award - please select for this nomination*


2. Identify your nominee

Title* First Name* (20) Last Name* (20)

IEEE Membership number (if applicable) (8)       and Grade

Location with regard to local IEEE Section*

P. Eng. Registration

Current professional affiliation and title*     and starting year*
(60)       Year (4)
(if nominee is retired, so state above and enter home address in the line below)

Business address*
(80)

Business Telephone No (15)       Business Fax No (15)

Home address
(80)

Home Telephone No (15)       Home Fax No (15)

Preferred Email Address* (50)

Education: (Institution, Degree, Year, Honours)*
(480)

3. Identify your first endorser

Title* First Name* (20) Last Name* (20)

IEEE Membership number* (8)       and Grade*

Address
(80)

Telephone No (15)       Fax No: (15)

Preferred Email Address* (50)

4. Identify your second endorser

Title* First Name* (20) Last Name* (20)

IEEE Membership number* (8)       and Grade*

Address
(80)

Telephone No (15)       Fax No (15)

Preferred Email Address* (50)

5. Identify yourself (Nominator)
If you are an IEEE member, please enter your membership number, grade and Section assignment. If you are not an IEEE member, please enter your address.

Title* First Name* (20) Last Name* (20)

IEEE Membership number (8)       and Grade

IEEE Section Assignment

IEEE Volunteer Position (if appropriate - state Position and Section Name or IEEE Canada)
(80)

Address
(80)

Telephone No (15)       Fax No (15)

Preferred Email Address* (50)

6. Proposed citation

Enter the citation you suggest for this award*
(80)

7. Documention of contributions and professional activity
(that are relevent to this award and the proposed citation)

Importance of contribution(s)*     (1200)


List Publications, Technical Presentations, etc.*     (800)
(state number of fully referreed journal publications, the total number of all publications, then list the five best that relate to this award)


List Patents, Proprietary Designs, etc.*     (800)


Description and Years of Relevant Professional Experience*     (800)


Service to the Engineering Profession (in IEEE & non-IEEE Professional Organizations) *     (800)


Recognition through other honours*     (800)


8. Your copy

You will automatically receive an email message containing a copy of your submission.   You can forward this message to your endorsers for their information.   Since this form is designed in a printer friendly format, you can use the PRINT button on your browser if you wish to make a printed copy of your completed form before you press submit.

9. Submit

Please double-check all entries before pressing submit.

or
Home Page / www.ieee.ca / Page d'accueil