IEEE REGION 5
OUTSTANDING ENGINEERING EDUCATOR
NOMINATION FORM

1. Nominee:_________________________________________________

2. Member No:________ Grade/year: (S,M,SM,F)____________

3. Professional Affiliation and Title:_______________________

4. Business Address:_________________________________________

Phone: (    )____ - ______

5. Residence Address:_________________________________________

Phone: (    )____ - ______

6. Education: (Include: Degrees, Institutions, Years, and Honors)

        ____________________________________________________________

        ____________________________________________________________

        _____________________________________________________________

7. Endorsements (two required):

Endorser:      _______________________________________________________

Member Number:_______________________________________________________

IEEE position:_______________________________________________________

Address:       _______________________________________________________

Phone:        (    )____ - ______

Endorser:      _______________________________________________________

Member Number:_______________________________________________________

IEEE position:_______________________________________________________

Address:       _______________________________________________________

Phone:        (    )____ - ______

8. Reason: State succinctly why the nominee should be honored.

9. Years of involvement in engineering education:

10. List Papers, Technical Presentations, Proprietary Designs, Patents, etc.:

11. Service to students and contributions to student activities:

12. Service to the IEEE:

13. Service to the Engineering Profession in non-IEEE professional organizations:

14. Recognition through other honors:

Submitted by: _______________________________________________________

Member Number:_______________________________________________________

IEEE position:_______________________________________________________

Address:       _______________________________________________________

Phone:        (    )____ - ______

The following are the weighting percentage points for the listed activities:

Must be IEEE member