NOMINATION FORM FOR AIS FELLOW

Nominations will close on October 15, 2006.

Please read the document AIS Fellow.
Information must be provided in the form below.  It must be limited to the space provided in the form.

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1. NAME OF CANDIDATE

First Name:

Middle Initial:

Last Name: 

Present Occupation(Position, Organization)

Business AddressLine #1: 

Business AddressLine #2: 

City: 

State/Province: 

Business Zip/PostalCode: 

Country: 

Telephone:

Fax number: 

E-mail address: 

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2. SUMMARY OF ACCOMPLISHMENTS: (100 words or less)

3. NOMINATOR:

First Name:

Last Name: 

Date: 

Nominator AddressLine #1: 

Nominator AddressLine #2: 

City: 

State/Province: 

Business Zip/PostalCode: 

Country: 

Telephone:

Fax number: 

E-mail address: 

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Direct questions regarding the content of this form to Claudia Loebbecke
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