CPSO
COUNCIL
AWARD
Please provide Nominator and Seconder
Statements and any additional information
in support of your nomination
T S TA N D I N G
NOMINATION FORM
OU
2020
NOMINEE
FIRST NAME:
LAST NAME:
NOMINEE'S ADDRESS:
EMAIL ADDRESS:
TELEPHONE:
DATE AND PLACE OF BIRTH:
DEGREES EARNED (DEGREE, SCHOOL, YEAR):
SPECIALTY, IF ANY:
TYPE OF PRACTICE:
FACULTY APPOINTMENTS, IF ANY:
PREVIOUS HONOURS AND AWARDS:
If you need more space, please attach additional pages.
NOMINATOR
FIRST NAME:
LAST NAME:
ADDRESS:
E-MAIL ADDRESS:
TELEPHONE NUMBER:
PLEASE INDICATE YOUR RELATIONSHIP TO THE NOMINEE:
SECONDER (must be provided)
FIRST NAME:
LAST NAME:
ADDRESS:
E-MAIL ADDRESS:
TELEPHONE NUMBER: