Council Member Candidate Nomination Form
Candidate Consent – Please print or type: 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
by 4:00 p.m. Tuesday, August 22, 2017.
*Forms can be sent by fax, email or mail.
Name:______________ ___________________________ CPSO Number:___________
SEND THE COMPLETED FORM TO:
Signature:______________________________________________________________
Home Tel.:_____________________________ Business Tel.: _____________________
Street Address:__________________________________________________________
______________________________________________________________________
City/Province/Postal Code:_________________________________________________
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 (as set out in the CPSO By-law); are not in default of a pay-
ment of fees owed to the College; and have a certificate of registration 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 referred to above, nominate the above-named candidate for
election:
74
Print Name
Signature CPSO Number
1. ____________________________________ ______________________________________ ________________________
2. ____________________________________ ______________________________________ ________________________
3. ____________________________________ ______________________________________ ________________________
4. ____________________________________ ______________________________________ ________________________
5. ____________________________________ ______________________________________ ________________________
6. ____________________________________ ______________________________________ ________________________
7. ____________________________________ ______________________________________ ________________________
Dialogue Issue 2, 2017