Dialogue Volume 13 Issue 2 2017 - Page 73

Council Member Candidate Nomination Form PLEASE NOTE: Information provided on this form will be circulated to all members of your district and will be posted on the College website www.cpso.on.ca. Your statement should briefly explain why you are running for election. The information contained in your statement must be con- sistent with the fact that Council members must act in the pu blic interest. Statements that are longer than 400 words or contain inappropriate statements will be returned for revision. Please Print or Type NAME: _______________________________________________________________________________________________________ TELEPHONE NUMBER (optional):__________________________________________________________________________________ (where members can contact you if they wish) MEDICAL DEGREES:____________________________________________________________________________________________ ____________________________________________________________________________________________________________ PLACE OF GRADUATION IN MEDICINE:_____________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ PRINCIPAL AREA OF PRACTICE OR SPECIALTY:_______________________________________________________________________ (e.g., family medicine, obstetrics and gynaecology, etc.) ADDRESS/LOCATION OF PRACTICE OR OFFICE:______________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ CURRENT HOSPITAL APPOINTMENTS:______________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Please e-mail your statement and a photograph to councilelections@cpso.on.ca (400 word limit). Issue 2, 2017 Dialogue 73