Council Member Candidate Nomination Form
Candidate Consent – Type or print only
DEADLINE FOR COMPLETED FORMS
I consent to allow my name to stand for election for Council Member in District #
____
Original forms must be received by the
College before 4:00 p.m. Tuesday,
August 26, 2014.
Name:______________ ___________________________ CPSO Number:___________
Mail the completed Original Form to:
Signature:______________________________________________________________
Home Tel.:___________________________
Business Tel.: _____________________
Street Address:__________________________________________________________
______________________________________________________________________
City/Province/Postal Code:_________________________________________________
CPSO Council Nomination – Att: T. Terzis
College of Physicians and Surgeons
of Ontario
80 College Street
Toronto, ON M5G 2E2
Faxes will be accepted on an interim basis
until the original is received. Fax to Tanya
Terzis at (416) 967-2666.
Please note: To stand for election, you must be nominated by five members of the College who are in good standing. We recommend that seven nominators be provided, in the event that a nominator is not in good standing. The
nominator must be eligible to vote in the district for which he or she is nominating the candidate.
NOMINATION
We the undersigned members in good standing with the College of Physicians and Surgeons of Ontario, nominate the abovenamed candidate for election.
Signature
CPSO Number
1. ____________________________________
______________________________________
________________________
2. ____________________________________
______________________________________
________________________
3. ____________________________________
______________________________________
________________________
4. ____________________________________
______________________________________
________________________
5. ____________________________________
______________________________________
________________________
6. ____________________________________
______________________________________
________________________
7. ____________________________________
58
Print Name
_______________________________