Dialogue Volume 15, Issue 2 2019 - Page 40

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: