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 (416) 967-2644
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