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 con-
sistent with the fact that Council members must act in the pu blic interest. Statements that are longer than 400 words or contain
inappropriate statements will be returned for revision.
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 e-mail your statement and a photograph to [email protected] (400 word limit).
Issue 2, 2017 Dialogue
73