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. Forms must be received by the College
by 4:00 p.m. Tuesday, August 21, 2018.
*Forms can be sent by fax, email or mail.
Name:___________________ ___________________________ District #:___________
CPSO Number:___________ SEND THE COMPLETED FORM TO:
Signature:______________________________________________________________ CPSO Council Nomination – Att: V. Clarke
College of Physicians and Surgeons
of Ontario
80 College Street
Toronto, ON M5G 2E2
Home Tel.:______________________________ Business Tel.: _____________________
Street Address:__________________________________________________________
______________________________________________________________________
City/Province/Postal Code:_________________________________________________
Fax: Vanessa Clarke 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 in 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 referred to above, nominate the above-named candidate for
election:
86
Print Name
Signature CPSO Number
1. ____________________________________ ______________________________________ ________________________
2. ____________________________________ ______________________________________ ________________________
3. ____________________________________ ______________________________________ ________________________
4. ____________________________________ ______________________________________ ________________________
5. ____________________________________ ______________________________________ ________________________
6. ____________________________________ ______________________________________ ________________________
7. ____________________________________ ______________________________________ ________________________
DIALOGUE ISSUE 2, 2018