Nomination Form
Medallion Award
To submit the nomination via e-mail, please complete this form and e-mail it as an attachment to
Honors@iienet.org.
If you can’t submit the nomination via e-mail, complete this form and submit it by mail,
postmarked by Dec. 1. Nominations sent by mail must include a total of eight copies of this
completed form. For either method of submission, do not attach published articles.
Mail to:
IIE Honors & Awards
c/o Office of the President
3577 Parkway Lane, Suite 200
Norcross, GA 30092
Questions? Call (770) 449-0461, ext. 105.
Nominee information
Name:
Address:
City, State, ZIP:
Work phone:
Home phone:
Fax number:
E-mail:
Date of birth:
Current position:
Required data
Provide details about the nominee’s accomplishments in professional leadership, professional
technical achievement, or both.
Nominator information
NOTE: Members of the IIE Board of Trustees, the Honors Steering Committee, those involved in
processing (such as the Director of Honors) and headquarters staff may not be used as a
reference for any nominee.
Name:
Address:
City, State, ZIP:
Work phone:
Home phone:
Fax number:
E-mail: