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