Dialogue Volume 13 Issue 2 2017 - Page 74

Council Member Candidate Nomination Form Candidate Consent – Please print or type: DEADLINES FOR COMPLETED FORMS I consent to allow my name to stand for election for Council Member in District #­­­­­­­­­­­­­____ Forms must be received by the College by 4:00 p.m. Tuesday, August 22, 2017. *Forms can be sent by fax, email or mail. Name:______________ ___________________________­­­­­­­­­­­­­ CPSO Number:___________ SEND THE COMPLETED FORM TO: Signature:­­­­­­­­­­­______________________________________________________________ Home Tel.:_____________________________ Business Tel.: _____________________ Street Address:__________________________________________________________ ______________________________________________________________________ City/Province/Postal Code:­­­­­­­­­­­­­­­­­­­­­­­­­­_________________________________________________ CPSO Council Nomination – Att: T. Terzis College of Physicians and Surgeons of Ontario 80 College Street Toronto, ON M5G 2E2 Fax: Tanya Terzis at (416) 967-2644 Email: councilelections@cpso.on.ca Please note: To stand for election, you must be nominated by five members of the College who: are eligible to vote in the district for which you are being nominated (as set out in the CPSO By-law); are not in default of a pay- ment of fees owed to the College; and have a certificate of registration that is not under suspension or revoked. We recommend that seven nominators be provided in the event that a nominator does not meet these criteria. NOMINATION We the undersigned members who meet the eligibility criteria referred to above, nominate the above-named candidate for election: 74 Print Name Signature CPSO Number 1. ____________________________________ ______________________________________ ________________________ 2. ____________________________________ ______________________________________ ________________________ 3. ____________________________________ ______________________________________ ________________________ 4. ____________________________________ ______________________________________ ________________________ 5. ____________________________________ ______________________________________ ________________________ 6. ____________________________________ ______________________________________ ________________________ 7. ____________________________________ ______________________________________ ________________________ Dialogue Issue 2, 2017