LOGIC March 2019 Vol 18 No 1 | Page 33

NOMINATION FORM FOR NZ COLLEGE OF PRIMARY HEALTH CARE NURSES LOGIC COMMITTEE I……………………………………………………………………………………... wish to nominate …………………………………………………………………………………………………………. (Surname) (Given Name) for the position of LOGIC Committee member, NZ College of Primary Health Care Nurses. Signed: ......................................................... Date: .................... (Nominator needs to be a member CPHCN) This section to be completed by Nominee I, .......................................................................................... accept nomination as a LOGIC Committee member of the NZ College of Primary Health Care Nurses. (Nominee needs to be a member of CPHCN) Address (Personal) ............................................................... Address (Business) ..................................................................... ............................................................... ..................................................................... ............................................................... ..................................................................... Ph/Fax: .................................................. Ph/Fax: ......................................................... E-mail:.................................................... E-mail: .......................................................... Area of current employment: ................................................................................................ NZNO Membership No. ....................................................................................................... Work Experience briefly: ............................................................................................................................................. ............................................................................................................................................. ............................................................................................................................................. Signature ............................................... Date .............................................. Please return the completed nomination form to the Returning Officer, NZNO, PO Box 2128, Wellington 6140 by 5pm on Friday 12 th July 2019 Email, fax or post to: to [email protected] Fax 04 3829993 New Zealand Nurses Organisation P O Box 2128 Wellington 6140 To be valid this form must be signed by both parties who must be members of CPHCN and be received by the closing date. March 2019 L.O.G.I.C 31