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 consistent with the fact that Council members must act in the public interest. Statements that are over 400 words or contain inappropriate statements will be returned for revision. Please email your photograph in a digital file to Tanya Terzis 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 attach your brief printed or typed statement to this sheet( 400 word limit)
Issue 2, 2016 Dialogue 73