Nomination Form 2019

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2019 NOMINATION FORM

if you are interested or know someone who you would like to nominate, please fill out this form by Friday November 23, 2018.

For which position are you nominating?

Your name:

Your email address:

What is your nominee's email address?

If you've nominated someone else, what is your nominee's name?

Has your nominee agreed to be nominated for this position?

yes

Who are you nominating for this position?

Enter the code displayed*

IPAC Greater Toronto Area
President: Murtuza Diwan BSc(Hons) MSc CIC
Halton Healthcare
3001 Hospital Gate
Oakville ON L6M 0L8
ipacgta@gmail.com