Council Member Candidate
Nomination Form
PLEASE NOTE: Information provided in Step 1 of this form will be circulated to all members of your district and will be
posted on the College website www.cpso.on.ca.
STEP 1 – Nominee Information
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:
STEP 2 – Statement
Your statement should briefly explain why you are running for election. The information contained in your statement must
be consistent with the fact that Council members must act in the public interest. Statements that are more than 400
words or contain inappropriate statements will be returned for revision.
Please email your statement (400 word limit) and a photograph to [email protected].
ISSUE 2, 2019 DIALOGUE
57