THE INSTITUTE OF ELECTRICAL AND ELECTRONICS ENGINEERS, INC.
NOMINATION FORM FOR
IEEE FOUNDERS MEDAL
The IEEE Founders Medal, for outstanding contributions in the leadership, planning, and administration of affairs of great
value to the electrical and electronics engineering profession. . To an individual or group, up to three in number. (See
Nominator Guidelines for Eligibility Requirements.)
1. Name
2. IEEE Member: Yes
No
IEEE Grade, Year
3. Year of Birth
IEEE Member #
Email
4. Professional Affiliation and Title
5. Business Address
6. Home Address
7. Education beyond twelfth grade. Honorary degrees denoted (H).
Institution/Location
Degree
Year
Honors
8. Endorsers, Names, Addresses, and Email. Endorsers should be familiar with the nominee’s achievements and should
state specific achievements that qualify the candidate for this award. Endorsers should also include a statement
indicating how long they have known the candidate and in what capacity. (Minimum of three supporting letters
required; maximum of five permitted. No more than five letters will be reviewed by the Committee. Letters may
accompany nomination or be submitted directly to IEEE.)
Do not exceed space provided. Attached pages are not permitted. Type no smaller than 10 point.
REV 10/06
9.
Proposed Citation. (No more than 25 words.)
10. Principal Employment: Year, Name of Company; Title; Brief, Concise Description of Responsibility.
11. Principal publications and/or patents pertinent to the achievement. (Prefer items of sole responsibility, otherwise
give joint names.)
Do not exceed space provided. Attached pages are not permitted. Type no smaller than 10 point.
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12. Achievements pertinent to the qualifications for the IEEE Founders Medal. (Criteria considered by the
Evaluation Committee shall include: outstanding leadership, planning, or administration of affairs related to the
profession; major industry administrator; manager of complex scientific mission; an additional consideration is
service to the IEEE beyond normal expectation. The quality of the nomination is also considered.)
Do not exceed space provided. Attached pages are not permitted. Type no smaller than 10 point.
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13. Principal IEEE Activities; Dates, Description.
14. Other Principal Professional Activities; Dates, Description.
15. Principal Honors (non-IEEE)
16. IEEE Honors/Awards
17. Nominator: Name, Business Affiliation and Address (or home address, if preferred); Telephone; Fax; Email.
17a. How long have you known the candidate and in what capacity?
NOTE: The IEEE Awards Board reserves the right to consider any nomination for Institute Awards other than the
award suggested when, in its judgment, the support and justification may more appropriately apply to other
Institute Awards.
Date:
______
Signature:
Submit to: IEEE Awards Activities, 445 Hoes Lane, Piscataway, NJ 08854
Tel:732.562.3844 Fax:732.981.9019; Email:awards@ieee.org
Do not exceed space provided. Attached pages are not permitted. Type no smaller than 10 point.
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