IEEE - IEEE Contact Center Callback Form

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Call back hours are Sunday 6:00 p.m. ET to Wednesday 4:00 p.m. ET. <p class="arrow-link"><a target="" href="/web/20100624022340/http://www.ieee.org/societies_communities/geo_activities/regional_world_map.html">IEEE Regions</a></p>Please provide your information below: <br/></p> </div>  </div> <div class="clearit"> </div> <div class="box-c"> <h2 class="bullet"><a class="nm" id="sect1" name="sect1">Callback Form</a></h2> <div> <p><script language="JavaScript" type="text/javascript" src="/web/20100624022340js_/http://www.ieee.org/ucm/groups/public/@ieee/@web/@org/@about/@help/documents/file/validate-autocallback.js"></script> <p align="left"><span style="color: rgb(255, 0, 0);">* required field</span></p> <form id="AutoCallbackForm" enctype="multipart/form-data" method="post" action="/web/20100624022340/http://www.ieee.org/ucm/idcplg?IdcService=GENERIC_FORM_HANDLER" name="AutoCallbackForm"><input type="hidden" name="data_order" value="First_Name,Last_Name,Region,Country,Member_Number,Telephone_Primary,Telephone_Alternate,submit_by,Contact_Date,Contact_Time,AMPM,Assistance_Type"/><input type="hidden" name="ok_url" value="/formconfirm/confirmation.html"/> <input type="hidden" name="not_ok_url" value="/formerror/error.html"/> <input type="hidden" name="submit_to" value="member-services-3@ieee.org"/> <input type="hidden" name="form_id" value="IEEE Contact Center Callback Form"/> <input type="hidden" name="required" value="First_Name,Last_Name,Region,Country,Telephone_Primary,submit_by"/> <table width="100%" cellspacing="2" cellpadding="3" border="0"> <tbody> <tr valign="middle"> <td valign="top" align="left" colspan="2"><strong>Contact Information</strong></td> </tr> <tr valign="middle"> <td width="225" valign="top" align="left">First/Given Name:<span style="color: rgb(255, 0, 0);">*</span></td> <td valign="top" height="21" align="left"><input type="text" size="40" name="First_Name" class="beveled"/></td> </tr> <tr valign="middle"> <td width="225" valign="top" align="left">Last/Family/Surname:<span style="color: rgb(255, 0, 0);">*</span></td> <td valign="top" align="left"><input type="text" size="40" name="Last_Name" class="beveled"/></td> </tr> <tr valign="middle"> <td valign="top" align="left">Region:<span style="color: rgb(255, 0, 0);">*</span></td> <td valign="top" align="left"><input type="text" size="40" name="Region" class="beveled"/></td> </tr> <tr valign="middle"> <td valign="top" align="left">Country:<span style="color: rgb(255, 0, 0);">*</span></td> <td valign="top" align="left"><select name="Country" style="border: 1px solid rgb(51, 51, 51);" class="border"> <option value="" selected="selected">-- Select One --</option> <option value="Albania">Albania</option> <option value="Algeria">Algeria</option> <option value="Andorra">Andorra</option> <option value="Angola">Angola</option> <option value="Anguilla">Anguilla</option> <option value="Antigua And Barbuda">Antigua And Barbuda</option> <option value="Argentina">Argentina</option> <option value="Armenia">Armenia</option> <option value="Aruba">Aruba</option> <option value="Australia">Australia</option> <option value="Austria">Austria</option> <option value="Azerbaijan">Azerbaijan</option> <option value="Bahamas">Bahamas</option> <option value="Bahrain">Bahrain</option> <option value="Bangladesh">Bangladesh</option> <option value="Barbados">Barbados</option> <option value="Belarus">Belarus</option> <option value="Belgium">Belgium</option> <option value="Belize">Belize</option> <option value="Benin">Benin</option> <option value="Bermuda">Bermuda</option> <option value="Bhutan">Bhutan</option> <option value="Bolivia">Bolivia</option> <option value="Bosnia And Herzegovina">Bosnia And Herzegovina</option> <option value="Botswana">Botswana</option> <option value="Brazil">Brazil</option> <option value="British Virgin Islands">British Virgin Islands</option> <option value="Brunei Darussalam">Brunei Darussalam</option> <option value="Bulgaria">Bulgaria</option> <option value="Burkina Faso">Burkina Faso</option> <option value="Burma">Burma</option> <option value="Burundi">Burundi</option> <option value="Cambodia">Cambodia</option> <option value="Cameroon">Cameroon</option> <option value="Canada">Canada</option> <option value="Cape Verde">Cape Verde</option> <option value="Cayman Islands">Cayman Islands</option> <option value="Central African Republic">Central African Republic</option> <option value="Chad">Chad</option> <option value="Chile">Chile</option> <option value="China">China</option> <option value="Colombia">Colombia</option> <option value="Comoros">Comoros</option> <option value="Congo">Congo</option> <option value="Cook Islands">Cook Islands</option> <option value="Costa Rica">Costa Rica</option> <option value="Cote D Ivoire">Cote D Ivoire</option> <option value="Croatia">Croatia</option> <option value="Cuba">Cuba</option> <option value="Cyprus">Cyprus</option> <option value="Czech Republic">Czech Republic</option> <option value="Denmark">Denmark</option> <option value="Djibouti">Djibouti</option> <option value="Dominica">Dominica</option> <option value="Dominican Republic">Dominican Republic</option> <option value="Ecuador">Ecuador</option> <option value="Egypt">Egypt</option> <option value="El Salvador">El Salvador</option> <option value="Equatorial Guinea">Equatorial Guinea</option> <option value="Eritrea">Eritrea</option> <option value="Estonia">Estonia</option> <option value="Ethiopia">Ethiopia</option> <option value="Falkland Islands">Falkland Islands</option> <option value="Fiji">Fiji</option> <option value="Finland">Finland</option> <option value="France">France</option> <option value="French Guiana">French Guiana</option> <option value="French Polynesia">French Polynesia</option> <option value="Gabon">Gabon</option> <option value="Gambia">Gambia</option> <option value="Georgia">Georgia</option> <option value="Germany">Germany</option> <option value="Ghana">Ghana</option> <option value="Gibraltar">Gibraltar</option> <option value="Greece">Greece</option> <option value="Greenland">Greenland</option> <option value="Grenada">Grenada</option> <option value="Guadeloupe">Guadeloupe</option> <option value="Guatemala">Guatemala</option> <option value="Guinea">Guinea</option> <option value="Guinea-bissau">Guinea-bissau</option> <option value="Guyana">Guyana</option> <option value="Haiti">Haiti</option> <option value="Honduras">Honduras</option> <option value="Hong Kong">Hong Kong</option> <option value="Hungary">Hungary</option> <option value="Iceland">Iceland</option> <option value="India">India</option> <option value="Indonesia">Indonesia</option> <option value="Ireland">Ireland</option> <option value="Israel">Israel</option> <option value="Italy">Italy</option> <option value="Jamaica">Jamaica</option> <option value="Japan">Japan</option> <option value="Jordan">Jordan</option> <option value="Kazakhstan">Kazakhstan</option> <option value="Kenya">Kenya</option> <option value="Kiribati">Kiribati</option> <option value="Korea">Korea</option> <option value="Kuwait">Kuwait</option> <option value="Kyrgyzstan">Kyrgyzstan</option> <option value="Laos">Laos</option> <option value="Latvia">Latvia</option> <option value="Lebanon">Lebanon</option> <option value="Lesotho">Lesotho</option> <option value="Liberia">Liberia</option> <option value="Liechtenstein">Liechtenstein</option> <option value="Lithuania">Lithuania</option> <option value="Luxembourg">Luxembourg</option> <option value="Macau">Macau</option> <option value="Macedonia">Macedonia</option> <option value="Madagascar">Madagascar</option> <option value="Malawi">Malawi</option> <option value="Malaysia">Malaysia</option> <option value="Maldives">Maldives</option> <option value="Mali">Mali</option> <option value="Malta">Malta</option> <option value="Martinique">Martinique</option> <option value="Mauritania">Mauritania</option> <option value="Mauritius">Mauritius</option> <option value="Mexico">Mexico</option> <option value="Moldova">Moldova</option> <option value="Monaco">Monaco</option> <option value="Mongolia">Mongolia</option> <option value="Montserrat">Montserrat</option> <option value="Morocco">Morocco</option> <option value="Mozambique">Mozambique</option> <option value="Myanmar">Myanmar</option> <option value="Namibia">Namibia</option> <option value="Nauru">Nauru</option> <option value="Nepal">Nepal</option> <option value="Netherlands">Netherlands</option> <option value="Netherlands Antilles">Netherlands Antilles</option> <option value="New Caledonia">New Caledonia</option> <option value="New Zealand">New Zealand</option> <option value="Nicaragua">Nicaragua</option> <option value="Niger">Niger</option> <option value="Nigeria">Nigeria</option> <option value="Niue">Niue</option> <option value="Norway">Norway</option> <option value="Oman">Oman</option> <option value="Pakistan">Pakistan</option> <option value="Panama">Panama</option> <option value="Papua New Guinea">Papua New Guinea</option> <option value="Paraguay">Paraguay</option> <option value="Peru">Peru</option> <option value="Philippines">Philippines</option> <option value="Pitcairn">Pitcairn</option> <option value="Poland">Poland</option> <option value="Portugal">Portugal</option> <option value="Qatar">Qatar</option> <option value="Reunion">Reunion</option> <option value="Romania">Romania</option> <option value="Russia">Russia</option> <option value="Rwanda">Rwanda</option> <option value="Saint Helena">Saint Helena</option> <option value="Saint Lucia">Saint Lucia</option> <option value="Samoa">Samoa</option> <option value="San Marino">San Marino</option> <option value="Sao Tome And Principe">Sao Tome And Principe</option> <option value="Saudi Arabia">Saudi Arabia</option> <option value="Senegal">Senegal</option> <option value="Serbia-montenegro">Serbia-montenegro</option> <option value="Seychelles">Seychelles</option> <option value="Sierra Leone">Sierra Leone</option> <option value="Singapore">Singapore</option> <option value="Slovakia">Slovakia</option> <option value="Slovenia">Slovenia</option> <option value="Solomon Islands">Solomon Islands</option> <option value="Somalia">Somalia</option> <option value="South Africa">South Africa</option> <option value="Spain">Spain</option> <option value="Sri Lanka">Sri Lanka</option> <option value="St Kitts And Nevis">St Kitts And Nevis</option> <option value="St Vincent And The Grenadines">St Vincent And The Grenadines</option> <option value="Sudan">Sudan</option> <option value="Suriname">Suriname</option> <option value="Swaziland">Swaziland</option> <option value="Sweden">Sweden</option> <option value="Switzerland">Switzerland</option> <option value="Syria">Syria</option> <option value="Taiwan">Taiwan</option> <option value="Tajikistan">Tajikistan</option> <option value="Tanzania">Tanzania</option> <option value="Thailand">Thailand</option> <option value="Togo">Togo</option> <option value="Tonga">Tonga</option> <option value="Trinidad And Tobago">Trinidad And Tobago</option> <option value="Tunisia">Tunisia</option> <option value="Turkey">Turkey</option> <option value="Turkmenistan">Turkmenistan</option> <option value="Turks And Caicos Islands">Turks And Caicos Islands</option> <option value="Tuvalu">Tuvalu</option> <option value="Uganda">Uganda</option> <option value="Ukraine">Ukraine</option> <option value="United Arab Emirates">United Arab Emirates</option> <option value="United Kingdom">United Kingdom</option> <option value="United States">United States</option> <option value="Uruguay">Uruguay</option> <option value="Uzbekistan">Uzbekistan</option> <option value="Vanuatu">Vanuatu</option> <option value="Venezuela">Venezuela</option> <option value="Vietnam">Vietnam</option> <option value="Wallis And Futuna Islands">Wallis And Futuna Islands</option> <option value="Western Sahara">Western Sahara</option> <option value="Yemen">Yemen</option> <option value="Yugoslavia">Yugoslavia</option> <option value="Zaire">Zaire</option> <option value="Zambia">Zambia</option> <option value="Zimbabwe">Zimbabwe</option> </select></td> </tr> <tr valign="middle"> <td width="225" valign="top" align="left">IEEE Member Number:</td> <td valign="top" align="left"><input type="text" maxlength="8" size="15" name="Member_Number" class="beveled"/></td> </tr> <tr valign="middle"> <td valign="top" align="left">Telephone (Primary):<span style="color: rgb(255, 0, 0);">*</span></td> <td valign="top" align="left"><label><input type="text" id="Telephone_Primary" name="Telephone_Primary" class="beveled"/> </label></td> </tr> <tr valign="middle"> <td valign="top" align="left">Telephone (Alternate):<span style="color: rgb(255, 0, 0);">*</span></td> <td valign="top" align="left"><label><input type="text" id="Telephone_Alternate" name="Telephone_Alternate" class="beveled"/> </label></td> </tr> <tr valign="middle"> <td valign="top" align="left">E-mail:<span style="color: rgb(255, 0, 0);">*</span></td> <td valign="top" align="left"><input type="text" size="40" name="submit_by" class="beveled"/></td> </tr> <tr valign="top" align="left"> <td colspan="2"> </td> </tr> <tr valign="top" align="left"> <td colspan="2"><strong>Assistance Information</strong></td> </tr> <tr valign="middle"> <td valign="top" align="left" colspan="2">Please specify a convenient date and time for an IEEE Contact Center Representative to call you.</td> </tr> <tr valign="middle"> <td valign="top" align="left" colspan="2"><label>Your Contact Date:<span style="color: rgb(255, 0, 0);">*</span><br/> <input type="text" id="Contact_Date" name="Contact_Date" class="beveled"/></label> (ex. 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