2012 IEEE Membership Application

(students and graduate students must apply online)

Start your membership immediately: Join online www.ieee.org/join
Please complete both sides of this form, typing or printing in capital letters. Use only English characters and abbreviate only if more than 40 characters and spaces per line. We regret that incomplete applications cannot be processed.

3

Please Tell Us About Yourself

Select the numbered option that best describes yourself. This information is used by IEEE magazines to verify their annual circulation. Please enter numbered selections in the boxes provided.
1. Computers 2. Computer peripheral equipment 3. Software 4. Office and business machines 5. Test, measurement and instrumentation equipment 6. Communications systems and equipment 7. Navigation and guidance systems and equipment 8. Consumer electronics/appliances 9. Industrial equipment, controls and systems 10. ICs and microprocessors 11. Semiconductors, components, sub-assemblies, materials and supplies 12. Aircraft, missiles, space and ground support equipment 13. Oceanography and support equipment 14. Medical electronic equipment 15. OEM incorporating electronics in their end product (not elsewhere classified) 16. Independent and university research, test and design laboratories and consultants (not connected with a mfg. co.) 17. Government agencies and armed forces 18. Companies using and/or incorporating any electronic products in their manufacturing, processing, research or development activities 19. Telecommunications services, telephone (including) cellular 20. Broadcast services (TV, cable, radio) 21. Transportation services (airline, railroad, etc.) 22. Computer and communications and data processing services 23. Power production, generation, transmission and distribution 24. Other commercial users of electrical, electronic equipment and services (not elsewhere classified) 25. Distributor (reseller, wholesaler, retailer) 26. University, college/other educational institutions, libraries 27. Retired 28. Other__________________________

INFORMATION Name & Contact Information 1 PERSONAL
Please PRINT your name as you want it to appear on your membership card and IEEE correspondence. As a key identifier for the IEEE database, circle your last/surname.
■ Male ■ Female Date of birth (Day/Month/Year)

/

/

Title ▼

First/Given Name

Middle

Last/Family Surname

Primary Address

■ Home ■ Business (All IEEE mail sent here)

Street Address City State/Province Postal Code Country

Primary Phone Primary E-mail ▼

Secondary Address ■ Home ■ Business
Department/Division

Company Name Title/Position Street Address Postal Code

B. Principal job function
1. 2. 3. 4. 5. 6. 7. 8. General and corporate management Engineering management Project engineering management Research and development management Design engineering management - analog Design engineering management - digital Research and development engineering Design/development engineering - analog

City Country

State/Province

Secondary Phone Secondary E-mail
To better serve our members and supplement member dues, your postal mailing address is made available to carefully selected organizations, to provide you with information on technical services, continuing education, and conferences. Your e-mail address is not rented by IEEE. Please check box only if you do not want to receive these postal mailings to the selected address. ■

9. Design/development engineering - digital 10. Hardware engineering 11. Software design/development 12. Computer science 13. Science/physics/mathematics 14. Engineering (not elsewhere specified) 15. Marketing/sales/purchasing 16. Consulting 17. Education/teaching 18. Retired 19. Other______________________

C. Principal responsibility
1. 2. 3. 4. 5. Engineering and scientific management Management other than engineering Engineering design Engineering Software: science/mngmnt/engineering 6. 7. 8. 9.

Education/teaching Consulting Retired Other _______________________

2
■ Yes

Attestation
■ No

I have graduated from a three-to-five-year academic program with a university-level degree. This program is in one of the following fields of study:

D. Title
1. 2. 3. 4. 5. 6. 7. 8. 9. Chairman of the Board/President/CEO Owner/Partner General Manager VP Operations VP Engineering/Dir. Engineering Chief Engineer/Chief Scientist Engineering Management Scientific Management Member of Technical Staff

■ Engineering ■ Computer Sciences and Information Technologies ■ Physical Sciences ■ Biological and Medical Sciences ■ Mathematics ■ Technical Communications, Education, Management, Law and Policy ■ Other (please specify): _________________
This academic institution or program is accredited in the country where the institution ■ No ■ Do not know is located. ■ Yes I have ______ years of professional experience in teaching, creating, developing, practicing, or managing within the following field:

10. Design Engineering Manager 11. Design Engineer 12. Hardware Engineer 13. Software Engineer 14. Computer Scientist 15. Dean/Professor/Instructor 16. Consultant 17. Retired 18. Other _______________________

Are you now or were you ever a member of IEEE? ■ Yes ■ No If yes, provide, if known: Membership Number Grade Year Expired

4

Please Sign Your Application

■ Engineering ■ Computer Sciences and Information Technologies ■ Physical Sciences ■ Biological and Medical Sciences ■ Mathematics ■ Technical Communications, Education, Management, Law and Policy ■ Other (please specify): _________________

I hereby apply for IEEE membership and agree to be governed by the IEEE Constitution, Bylaws and Code of Ethics. I understand that IEEE will communicate with me regarding my individual membership and all related benefits. Application must be signed.

Signature Date

Over Please

A. Primary line of business

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