IEEE Standards Association (IEEE-SA)
Nominations and Appointments Committee
Form for Membership on IEEE-SA Governance Boards
Name:
Email:
Phone:
Country of residence:
Employer:
Present job title:
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
IEEE-SA Governance Board on which membership is desired [Choose one]:
IEEE Standards Association Board of Governors (BOG)
__________________
IEEE Standards Association Standards Board (SASB)*
__________________
*If membership on the SASB is not attained, indicate whether you would be willing to
serve on one of its Standing Committees [Audit Committee (AudCom), Industry
Connections Committee (ICCom), New Standards Committee (NesCom), or Standards
Review Committee (RevCom)]:
Yes_________ No__________
IEEE Member:
Yes [Include membership number] _______________
IEEE-SA Member: Yes _____________
No______
No______
Please list any current or past service on the BOG, SASB, or their committees:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Member of the following IEEE Societies:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Participant in the standards development activities of the following IEEE-SA Standards Sponsors:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Leadership positions held in the Sponsors noted above:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Copyright ©2014 IEEE
Education (Undergraduate and Graduate levels):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Participant in the activities of the following non-IEEE standards development organizations:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Leadership positions held in the non-IEEE standards development organizations noted above:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Relevant work experience in industry, academia, and government:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Relevant achievements (e.g., papers/articles published, awards, patents, etc.)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Candidate statement [optional]:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please send completed form to:
David Ringle
Director, IEEE-SA Governance
d.ringle@ieee.org
Fax: +1 732 875 0524
Copyright ©2014 IEEE