Dialogue Volume 15, Issue 2 2019 - Page 57

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 councilelections@cpso.on.ca. ISSUE 2, 2019 DIALOGUE 57