Dialogue Volume 11 Issue 2 2015 | Page 74

Council Member Candidate Nomination Form DEADLINES FOR COMPLETED FORMS Candidate Consent – Type or print only I consent to allow my name to stand for election for Council Member in District #­­­­­­­­­­­­­ ____ Name:___________________________­­­­­­­­­­­­­ CPSO Number:_________________________ Signature:­­­­­­­­­­­______________________________________________________________ Home Tel.:___________________________ Business Tel.: _____________________ Street Address:__________________________________________________________ ______________________________________________________________________ City/Province/Postal Code:­­­­­­­­­­­­­­­­­­­­­­­­­­_________________________________________________ Forms must be received by the College before 4:00 p.m. on Tuesday, August 25, 2015.* Forms can be sent by fax, email or mail. SEND THE COMPLETED FORM TO: CPSO Council Nomination – Att: T. Terzis College of Physicians and Surgeons of Ontario 80 College Street Toronto, ON M5G 2E2 Fax: Tanya Terzis at [phone] Email: [email protected] 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; not in default of payment of fees owed to the College; and who have a licence 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 of the College of Physicians and Surgeons of Ontario, nominate the above-named candidate for election. Print Name Signature CPSO Number 1. ____________________________________ ______________________________________ ________________________ 2. ____________________________________ ______________________________________ ________________________ 3. ____________________________________ ______________________________________ ________________________ 4. ____________________________________ ______________________________________ ________________________ 5. ____________________________________ ______________________________________ ________________________ 6. ____________________________________ ______________________________________ ________________________ 7. ____________________________________ ______________________________________ ________________________ note: If you require mailing labels for campaigning to the voters in your district, please complete and submit a signed consent form by August 25, 2015. 74 Dialogue Issue 2, 2015