ELECTRONIC AWARD NOMINATION FORM

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INSTRUCTIONS: Use one form for each nomination. Please review the award criteria carefully, and use this form only for information relevant to the award criteria. Attach any appropriate supporting documentation. If the nomination is based on published works, provide at least one copy of the document. PLEASE INCLUDE ONLY RELEVANT INFORMATION. Complete all information, and then email the completed form to the System Safety Society address above or to Tony Burno directly at . If you have any questions, or need more information, please contact Tony Burno, OVP Awards, 540-663-9471. Thank you! Nominations are due by May 15th each calendar year. Completed form should not exceed 4 pages.

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AWARD TYPE
___ Professional Development Award ___ Manager of the Year Award
___ Engineer of the Year Award ___ Educator of the Year Award
___ Scientific Achievement Award ___ International Award
NOMINEE PROFILE
___ Individual ___ Group (If nominating a group, please provide the following information for the Group Leader):
Nominee Name:
Society Membership Status:
The Following Address Is: ___ Company Address ___ Home Address
Address:
City, State, Zip, & Country:
Work & Home Telephone:
Company:
Current Job Title:
Email:
Supervisor Name:
Supervisor Email:
NOMINATOR PROFILE
Nominator Name:
Nominator Society Membership Number & Status:
Nominator Work & Home Telephone:
Nominator Email:
NOMINATION JUSTIFICATION
Description of Current Position or Organizational Purpose:
Qualifying Achievements During the Past Year (May 15th through May 14th):
Key Contributions to System Safety:
Relevant Degrees, Certifications, and Professional Credentials (e.g., Ph.D. CSP, PE, etc.):
Qualifying Achievements Throughout Nominee’s Career (COMPLETE THIS SECTION ONLY IF NOMINATING FOR PROFESSIONAL DEVELOPMENT AWARD):

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List Of Publications, Articles, etc.:
Other Relevant Professional Information:
Why Do You Feel This Nominee Should Receive This Award?

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REFERENCES
Please list three references who can provide comments about the nominee’s qualifications for this award. Please note that at least one reference must be a member of the System Safety Society. Persons listed as references cannot be related to or employed by the nominee.
Name / Postal and Email Addresses / Telephone

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