IEEE WIE Affinity Group Special Funding Request Form

Last Name:

IEEE Membership Number:

Email address:

Phone Number:

IEEE WIE Volunteer position:

IEEE WIE Affinity Group Name and Number / Society name:

Title of Activity:

Date of Activity: month/day/year

Description of Activity:

Provide details of the activity (500 words or less). Include information such as objectives, audience, alignment with IEEE WIE mission/vision, benefits to WIE membership/community, advertising plan, and evaluation of activity.

Total Number of Participants Expected:

Number of IEEE Members:

Number of Non-members:

Identify Other sources of funding solicited. Include sources and amounts requested.

Amount of WIE funding requested:

Please complete the required Budget Plan document (linked at the bottom of this form) and send to wie-funding@ieee.org.

Describe how the effectiveness of the activity will be evaluated.

Important: Funds must be sent by check, wire transfer, or through a concentration banking account. Funds will not be sent to or made out to an individual. If a group does not have an account to transfer funds, the funds may be sent to a Section for forwarding to the group.

Provide Section Treasurer (Name/Contact Information):

Wire Transfer Information (WIE Affinity Group Transfer):

Bank Name:

Bank Address:

City:

Country/Region

Bank Acct Name:

Bank Acct or IBAN#:

Instructions for Wire:

Internal GL Account Number (Society Transfer):

Concentration Banking Account Number:

Budget Plan*: Please complete the required template and send to wie-funding@ieee.org

Your Activity Report must be submitted to wie-funding@ieee.org within thirty (30) days after the conclusion of the activity. Funding will be provided after the activity is held and upon receipt of the activity report.