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» Membership » MD » MD Programs » SM Program
Senior Member Reference Form
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Please note that submitting this reference form does not by itself constitute a nomination in conjunction with the Nominate a Senior Member Initiative. In order for the Section or Society to qualify for the NSI rebate of $10 per successful nomination, the nomination section of the SM Application Form must be filled in completely including the name of the nominating entity.

For any questions relating to the Senior Member application process, send your inquiry to senior-member@ieee.org

TO BE COMPLETED BY THE IEEE SENIOR MEMBER OR FELLOW SERVING AS REFERENCE
Name of Applicant:
Applicant's member number (if known)
A. Do you know the candidate professionally?

If yes, how long?

 years

What is your professional relationship to the candidate?
B. Has the candidate been in active professional practice for at least 10 years?
Total years in the profession
C. In your own words, explain how the candidate has significantly performed his/her professional duties for at least five years. (See Examples of Significant Performance). (Use as much space as you need)
D. Please indicate whether you consider the candidate to be:
INFORMATION ABOUT THE IEEE MEMBER SERVING AS REFERENCE
My Name:
My IEEE Membership Number (required) :
My IEEE Membership Grade:
Date:

          

 
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(Modified:21-Jun-2005)