Return This Form To

Return this form to: [email protected]

WORKING GROUP CHAIR AWARDS

Date of Request: 1 February 2015 IEEE Standard # and Title: IEEE Std 123456-2015 “IEEE Recommended Practice for xxxxxxx

OFFICER AWARDS (PLAQUES) FULL NAME SHIP TO - COMPLETE MAILING ADDRESS & PHONE (no P.O. Boxes) WG Chair: John A. Doe 123 Main Street City, State, Zip – Country Phone number WG Co-Chair(s) (if applicable) Jane Doe “ WG Vice Chair (if applicable) John A. Doe, Jr. “ WG Task-Force Chair (if John A. Doe, Jr. applicable) “

Technical Editor (if applicable) John B. Doe “ Special Editor (if applicable) John B. Doe, Jr. “

CERTIFICATE OF APPRECIATION (if applicable): SHIP TO - COMPLETE MAILING ADDRESS & PHONE (no P.O. Boxes) Name: Joseph Doe 123 Washington Avenue Reason: assisted the technical editor with the std Piscataway, NJ 08854 732-555-1212 Name: Charles Doe Reason: hosted many of the WG meeting at his company “ Name: Robert Doe Reason: was a driving force for the creation of the standard “ Name: Reason: Return this form to: [email protected] WORKING GROUP CHAIR AWARDS

If these awards need to be shipped to a meeting venue, a valid shipping address and recipient’s full contact information must be received at least six (6) weeks prior to the meeting date.

Full Contact Information SHIP TO - COMPLETE MAILING ADDRESS & PHONE (no P.O. Boxes) Full Name: Tel:

Special instructions: