This form is to be used in conjunction with a recently submitted nomination form for the Industry Leadership Award.

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 endorsement.   The email address you enter in part 3 will be used by the IEEE Canada Awards Committee to respond to your endorsement.

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.

Note: Your entries to parts 1,2,3 should be identical to those entered by the nominator

1. Select the Award             Submission date*   2011 2012 2013 2014 January February March April May June July August September ? October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 ? 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

There in one industry leadership award - please select for this nomination *
Select Award Industry Leadership Award

2. Identify the nominee

Title* Mr. Mrs. Miss Ms. Dr. Prof. First Name* (20) Last Name* (20)

IEEE Membership number (8)       and Grade Select Grade Fellow Senior Member Member Associate Member Student Member
(if nominee is an IEEE member)

3. Identify yourself (Endorser)

Title* Mr. Mrs. Miss Ms. Dr. Prof. First Name* (20) Last Name* (20)

IEEE Membership number* (8)       and Grade* Select Grade Fellow Senior Member Member Associate Member Student Member

IEEE Section Name * (30)

Preferred Email Address* (50)

4. Identify the nominator

  Last Name* (20)

5. Endorsement

Please provide your endorsement of the nomination*     (2400)


6. Your copy

You will automatically receive an email message containing a copy of your submission.   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.

7. Submit

Please double-check all entries before pressing submit.

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