IEEE Nuclear and Plasma Sciences Society
Nomination for the Medical Imaging Scientist Award

The nominator should provide the information requested in the following nomination form. Please do not submit materials beyond those requested.  

This form is available in both RTF (for use in Microsoft Word) and PDF formats. If you are using Word, you can type the requested information directly into this document. Otherwise, use additional sheets to answer parts 3-9.

1. 	Candidate
Name (first, middle, last):	
Title: 	
Organization:	
Work address:	

Home address:	

Phone number(s):	
e-mail address:	
IEEE member?  Yes		No		If yes, Member no.

2. 	Nominator
Name (first, middle, last):	
Signature:	  Date: 
Title: 	
Organization:	
Address:	

Phone number(s):	
e-mail address:	
IEEE Member number	

3. 	Proposed citation (30 words or less; typically stated as “For contributions to…”)

4. 	Education
Educational Institution	Location	Degree	Year

5. 	Professional history
Time period	Organization	Position held and responsibilities

6. 	Description of candidate’s technical achievements and other contributions to the field of medical imaging science (not to exceed 2 pages)
7. 	List of candidate’s ten most significant publications and patents  
8. 	Submit copies of three representative publications
9. 	Submit two additional letters in support of the candidate (not to exceed 2 pages each)