NOMINATION FORM

South Australian/Northern TerritoryRegional Committee
Casual Vacancy Positions

We, the undersigned, being full financial Fellowsof the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), resident inSouth Australia/Northern Territory,nominate the below Fellow for electionas a Fellow Representative to theSouth Australian/Northern TerritoryRegional Committee until September2019.

  1. Nominee Details

Title / First Name (s)
Surname
Position (please tick) /  Fellow Representative  Provincial Fellow Representative
Email
  1. Proposer Details (Proposer to complete all sections)

Title / First Name(s)
Surname
Signature / Date
  1. Seconder Details (Seconder to complete all sections)

Title / First Name(s)
Surname
Signature / Date
  1. Nominee Declaration(Nominee to read and complete the following declaration)

I,( insert full name) / ,
being a full financial Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, resident in South Australia/Northern Territory, hereby accept nomination for election to the South Australian/Northern Territory Regional Committeeuntil September 2019.
Signature / Date

Candidate Statement:

This is a fillable form to enable the information to be typed electronically in the grey shaded fields. Should you prefer to complete the form by hand, please print clearly as text provided will be reproduced verbatim in election materials.

Please note: Strict word limits apply, where indicated; please ensure that these limits are adhered to, as only the maximum word limit specified will be reproduced in ballot documentation, where required.

  1. Principal Current Appointment(please specify)

  1. Statement of Past/Current Involvement in College Activities(maximum 300 words)

  1. Statement of What You Wish to Achieve if Elected(maximum 500 words)

Please provide your statement below or tick here if attaching an accompanying document as your statement.
IMPORTANT NOTE:
For a nomination to be accepted, the completed Nomination Form must be received at College House not later than 12 Noon (AEDT) Tuesday 12 December 2017by one of the following delivery methods:
Post: Election Office, RANZCOG, College House, 254-260 Albert Street, East Melbourne VIC 3002, Australia
Email: | Facsimile: +61 (03) 9419 0672

COLLEGE HOUSE 254–260 Albert Street, East Melbourne, VIC 3002, Australia | ABN 34 100 268 969
TEL: + 61 3 9417 1699 | FAX: +61 3 9419 0672 | EMAIL: | WEB: