This form is to be used for the following awards; W.S. Read Outstanding Service Award, J.J. Acchambault Eastern Canada Merit Award, M.B. Broughton Central Canada Merit Award, E.F. Glass Western Canada Merit 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*   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 are four IEEE Canada service awards - please select the one for this nomination*
Select Award W.S. Read Outstanding Service Award J.J. Archambault Eastern Canada Merit Award M.B. Broughton Central Canada Merit Award E.F. Glass Western Canada Merit Award

2. Identify your 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

IEEE Section Assignment* List of Canadian IEEE Sections Canadian Atlantic Hamilton Kingston Kitchener-Waterloo London Montreal New Brunswick Newfoundland & Labrador North Saskatchewan Northern Canada Ottawa Peterborough Quebec Saint Maurice South Saskatchewan Southern Alberta Toronto Vancouver Victoria Winnipeg

P. Eng. Registration Province or Territory Not Registered British Columbia Yukon Nunavut Alberta Saskatchewan Manitoba Ontario Quebec New Brunswick Nova Scotia Prince Edward Island Newfoundland & Labrador

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)*
(320)

3. Identify your first 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

Address
(80)

Telephone No (15)       Fax No: (15)

Preferred Email Address* (50)

4. Identify your second 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

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* 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 Assignment List of Canadian IEEE Sections Canadian Atlantic Hamilton Kingston Kitchener-Waterloo London Montreal New Brunswick Newfoundland & Labrador North Saskatchewan Northern Canada Ottawa Peterborough Quebec Saint Maurice South Saskatchewan Southern Alberta Toronto Vancouver Victoria Winnipeg

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 professional activity and service contributions
(that are relevent to this award and the proposed citation)

Importance of contribution(s)*     (1200)


List Relevent Publications and/or Presentations on Volunteer Activities*     (800)
(state number of publications and number of presentations, then list the five best that relate to this award)


IEEE Service Record at the Section or Area Level - list volunteer positions and dates *     (800)


IEEE Service Record at the National or International Level - list volunteer positions and dates *     (800)


Service to the Engineering Profession in non-IEEE Professional Organizations*     (400)


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

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