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Conference/Symposium Name/Title:

Location of Conference:

Date(s) of Conference:

Amount of Seed Funding Being Requested from IEEE:

This Seed Funding Request Represents ______ % of the total sponsorships

Industry Exhibits: YES ___ NO ___

Estimated Attendance:

Host Society:

Host Section:

Other IEEE entities involved:

Other non-IEEE entities involved:

Conference Chairperson:

Finance Committee Chairperson:

Address of Conference Correspondence:

Tel: __________________ Fax: ________________

Request Submitted by:

Address:

Conference Position:

Tel: __________________ Fax: ________________

Signature: _______________________________ Date: ______________

Attachments Required:

(1) Please provide a copy of the Preliminary Budget.

(2) Please provide a copy of conference meeting minutes to date.

(3) List of other committee members