IEEE Nuclear and Plasma Sciences Society
Nomination for the Medical Imaging Science Young Investigator Award

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 

6. 	Description of candidate’s technical achievements (not to exceed two pages)
7. 	List of no more than 10 of the candidate’s most significant publications and patents   
8. 	Submit copies of (at most) three representative publications
9. 	Submit two additional letters in support of the candidate (not to exceed two pages each)