IACR ELECTION NOMINATION FORM

I nominate _______________________________ for the position(s) of _____________________________

Nominator:

__________________________________________ __________________________________________
Name (print) Signature

__________________________________________ __________________________________________
Date Fax number

__________________________________________ Address ____________________________________
Email
_______________________________________

_______________________________________

I, ___________________________________________________, accept this nomination

Candidate's statement (max. 50 words): ______________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Nominee:

_________________________________________ ________________________________________
Name (print) Signature

__________________________________________ ________________________________________
Date Fax number

__________________________________________ Address _________________________________
Email
________________________________________

________________________________________

Return this form by mail or fax to Bart Preneel
(See previous page for address and deadline.)