Dialogue Volume 14 Issue 2 2018 - Page 85

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 public interest. Statements that are more than 400 words or contain inappropriate statements will be returned for revision. Please email your photograph in a digital file to Vanessa Clarke at councilelections@cpso.on.ca. 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 statemen t (400 word limit) and a photograph to councilelections@cpso.on.ca. ISSUE 2, 2018 DIALOGUE 85