SIMD Membership Application Recommendation

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Date of Recommendation

	MM		DD		YYYY
Date	Date of Recommendation   Date   Month	/	Day	/	Year

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Information on Person Making Recommendation

Information on Person Making Recommendation   First Name
Last Name
Position
Institution

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Email Address

Email Address

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Person You Are Recommending

Person You Are Recommending   First Name
Last Name

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Depth of Knowledge about Applicant

Depth of Knowledge about Applicant   Know very well Know reasonably well Acquaintance Know by reputation Know by reputation of program or trainer Do not know personally or professionally

Other (please specify)

I recommend this candidate for SIMD membership:

I recommend this candidate for SIMD membership:   With great enthusiasm With enthusiasm Somewhat neutral With Reservations With strong reservations

Comments:

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Please provide a sentence or two describing the candidate in words that would be useful for a ballot to the general membership.

Please provide a sentence or two describing the candidate in words that would be useful for a ballot to the general membership.

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By checking this box I acknowledge that the information contained in this form is accurate and represents my true opinions about this candidate.

By checking this box I acknowledge that the information contained in this form is accurate and represents my true opinions about this candidate.   I acknowledge I do not acknowledge (this form will be discarded)

Other (please specify)