Young Female Leader Professional Development Award
Application Form
A Your Details
Title
First Name
Family Name
Date of Birth
DD/MM/YYYY
Home Address
County/State
Postcode
Home Phone
Country
Mobile
Home Email
B Current Employment
Employer
Job Title
Business Address
County/State
Postcode
Country
Business Phone
Business Email
Which address would you like all correspondence sent to?
Home
Business
C Your Interests
What are your area(s) of interest? (tick all that apply):
Digital Circuits & Systems
Sciences
VLSI
Digital Signal Processing
Memory Design
MEMS
System on Chip
Mixed Signal Circuits & Systems
Analog Circuits and Systems
RF Circuits & Systems
Device Modelling
D Membership
In order to apply for this award, you will first need to be a member of the IEEE CAS
I wish to apply to become a Member of the IEEE CAS
I am already a Member of the CAS
Membership Number:
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Biomedical & Life
Design For Test
Young Leaders Professional Development Award
Application Form
E Education
Start Date
End Date
Course/Qualification Title
Educational Institutions / Schools
F Professional Development
Start Date
End Date
Company & & Job Title
Experience
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Young Leaders Professional Development Award
Application Form
G Professional Services, Papers Presented, Awards etc.
Date
Title
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Young Leaders Professional Development Award
Application Form
H Comments
Comments on Personal Capability.
Based on your achievements in the CV, within half a page, please summarise your achievements and give a self-assessment
of your best contribution.
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Young Leaders Professional Development Award
Application Form
I Declaration
I declare that the statements made on this form are to the best of my knowledge true.
I understand and consent to the information provided on this form being processed by the IEEE for nomination purposes. I also
understand and consent that the information will be used by the IEEE and any of its associated organisations for the purposes
of promoting, delivering and improving my experience of the IEEE, its products and its services, by post and electronic means.
Signature of Candidate
Date
J Supporters’ Details
We, the undersigned, support the candidate from personal knowledge, as a person worthy of consideration for the Award and
we endorse the correctness of this form.
Supporter 1 (mandatory)
Name
(print)
Address for communication
Postcode
Signature
(sign)
Date
Phone
Email
Membership Number (if applicable)
Supporter 2 (optional)
Name
(print)
Address for communication
Postcode
Signature
(sign)
Date
Phone
Email
Membership Number (if applicable)
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