Dialogue Volume 12 Issue 2 2016 | Page 74

Council Member Candidate Nomination Form Candidate Consent – Type or print only DEADLINES FOR COMPLETED FORMS I consent to allow my name to stand for election for Council Member in District #­­­­­­­­­­­­­____ Forms must be received by the College before 4:00 p.m. Tuesday, August 23, 2016. *Forms can be sent by fax, email or mail. Name:______________ ___________________________­­­­­­­­­­­­­ CPSO Number:___________ Signature:­­­­­­­­­­­______________________________________________________________ Home Tel.:_____________________________ Business Tel.: _____________________ SEND THE COMPLETED FORM TO: Street Address:__________________________________________________________ CPSO Council Nomination – Att: T. Terzis College of Physicians and Surgeons of Ontario 80 College Street Toronto, ON M5G 2E2 ______________________________________________________________________ City/Province/Postal Code:­­­­­­­­­­­­­­­­­­­­­­­­­­_________________________________________________ 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 license 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 who meet the eligibility criteria identified above, nominate the above named candidate for election. 74 Print Name Signature CPSO Number 1. ____________________________________ ______________________________________ ________________________ 2. ____________________________________ ______________________________________ ________________________ 3. ____________________________________ ______________________________________ ________________________ 4. ____________________________________ ______________________________________ ________________________ 5. ____________________________________ ______________________________________ ________________________ 6. ____________________________________ ______________________________________ ________________________ 7. ____________________________________ ______________________________________ ________________________ Dialogue Issue 2, 2016 Issue2_16.indd 74 2016-06-16 12:28 PM