Name of Local Medical Committee

Name of Local Medical Committee

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NewhamLocal Medical Committee (LMC) & City and East London LMC

Nomination Form 2013for the Newham constituency

PLEASE USE BLOCK CAPITALS

Section one: Candidate’s details (to be completed by the candidate)

In order to stand for election a candidate must:
  1. be a GP working in the LMC constituency area
  2. be supported by two other GPs in the LMC constituency area
Candidates will be listed in alphabetical order on the ballot paper. A candidate’s first name will be listed but not their title. The candidate’s election statement will be circulated with the ballot paper.
Full name
Address for correspondence
Postcode / Contact telephone number
Email address
Please note: Address and telephone information is for the sole use of Londonwide Local Medical Committees Limited, so that we can contact you about your nomination form. This information will remain confidential.
I, the above named candidate, consent to my nomination and agree to stand for election. I confirm that, to the best of my knowledge, the information provided on (or with) this form is accurate.
Signature / Date

Section two: supporters’ details (to be completed by two supporters from the LMC constituency area)

1. / Full name
Practice / Signature
2. / Full name
Practice / Signature

please turn over

Election statement (to be completed by the candidate)

Candidate’s election statement preparation instructions
  • You are invited to provide an election statement, either on this form or on a separate sheet of paper. This will be reproduced and circulated to voters with the ballot papers.
  • The election statement should describe why you think you should be elected.
  • The election statement must not be more than 50 words and where possible should be word-processed. If this is not an option please print clearly below.
  • Please state the total number of words used at the end of the election statement.
  • The organisation reserves the right not to publish, or to edit, any election statement that exceeds the maximum 50 word limit, is factually inaccurate or contains libellous material.

Please print your statementhere using block capitals

Total number of words used (maximum 50) _____

Close of nominations

  • This nomination form must REACHLondonwide LMCs Ltd, Tavistock House North, Tavistock Square, London, WC1H 9HXno later than 5.00pm on Friday25 October2013. Nomination forms received after this date will not be considered valid.
  • You can also send your election statement by email to You should put ‘Londonwide LMCs’ and your name as the subject title. Please note that you should still send the nomination form in with a copy of the printed statement attached.
  • A faxed nomination form will be accepted – fax number 020 7383 7442. Please note that faxes can be difficult to read so when sending forms by fax, candidates are strongly encouraged to email a typed version of the election statement to to prevent transcription errors.
  • The safe return of this form is the responsibility of the candidate. All nomination forms received will be acknowledged within three working days by second class post and email to the addresses provided.
  • If you require any further information on completing this nomination form please contactNic Kirwan-Williams on 020 7387 2034 ext 243 or by email on

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