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William W. Middleton Award Nomination Form

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Nominee
   
Name*:
Member #*:
Address*:
City*:
State/Province*:
Postal Code*:
Country*:
Email*:
Phone (H):
Phone (O):

Responsibilities
   
Current Responsibilities*:
Previous Responsibilities*:
Length of Service*:
Significant Nature of Achievement*:
Suggested Citation*:

Endorsement
       
1. Name*: Member #*:
2. Name*: Member #*:
3. Name*: Member #*:

Nominator
   
Nam*e:
Member #*:
Address*:
City*:
State/Province*:
Postal Code*:
Country*:
Email*:
Phone (H):
Phone (O):

Acknowledgement of Regional Director
 

Additional Comments
 
 

PLEASE USE ONE ADDITIONAL PAGE IF NECESSARY: The MGA Awards and Recognition Committee reserves the right to consider any nomination for awards other than the award suggested when, in its opinion, the support and justification may more appropriately apply to other MGA Awards. MGA awards are peer-recognized awards, therefore, SELF NOMINATION IS NOT PERMITTED.


 MGA Awards & Recognition Program
• Award Recipients
• Nominations Process
• Region Awards
• MGA Awards Program Manual (PDF, 290KB)
• IEEE Awards


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