IEEE REGION 3

EMPLOYER PROFESSIONAL DEVELOPMENT AWARD NOMINATION FORM

• Name of Organization being nominated:   _________________________________
  
• Name of contact within nominated organization:
  
  Address:   _________________________________
                   _________________________________
  Phone:      _________________________________
  Fax:           _________________________________
  E-mail address (if available): _________________________________

• Endorsements:
                          

  a.    IEEE member employee	b.     Section Chair
  Name:       _____________________	Name:       _____________________
  IEEE Member Number: ______________	IEEE Member Number: ______________
  Address:    _____________________                   _____________________	Address:    _____________________                   _____________________
  Phone (O): _____________________	Phone (O): _____________________
  Phone (H): _____________________	Phone (H): _____________________
  Fax:            _____________________	Fax:            _____________________
  E-mail:       _____________________	E-mail:       _____________________

Section: _____________________

• Additional endorsements (optional)
  

  Name:       _____________________

  IEEE Member Number: ______________

  Address:    _____________________                   _____________________

  Phone (O): _____________________

  Phone (H): _____________________

  Fax:            _____________________

  E-mail:       _____________________

• Citation (Suggested) (Please limit to 25 words or less):
  Example: "For Outstanding Contributions To Employee Continuing Education And Professional Development"

• Nominator Information:

  Name:       _____________________

  Member Number & Grade: ______________

  Address:    _____________________                   _____________________

  Phone (O): _____________________

  Phone (H): _____________________

  Fax:            _____________________

  E-mail:       _____________________

  Position within nominated organization:            _____________________

  IEEE position: _____________________

State why the nominated organization is deserving of recognition, keeping in mind the purpose of the award and the organization's contributions to employee continuing education and professional development.

Describe the SPECIFIC significant or outstanding organization contributions or achievements which made you decide to submit this nomination.

Elaborate on the factors which suggest to you that the above contributions are substantially above and beyond those to be expected of an organization employing technical personnel.

Provide any other details and supporting information which would help the committee make an informed decision. (Additional documentation may be attached. Please limit to five pages maximum.)

Nominator's Signature: _______________________________ Date: ____________