Nomination Form – IEPA New Vice President Roles

Please complete the following details by 15th September, 2021
This form must be completed and signed by two nominators as well as the candidate. The candidate must be primarily resident and have their main employment in the region covered by the Vice Presidency for which the candidate seeks election.
The IEPA board recognises that early intervention in mental health networks are less developed in some of these regions. Therefore, if you wish to stand for election in your region, but you do not know two nominators, existing IEPA board members can fulfil this function.
Please contact the IEPA office secretariat@iepa.org.au if you require this kind of support to nominate.

Candidate's Preferred Title*

Candidate's Name*

First Last

Candidate's Email*

Candidate's Place of Work*

Candidate's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Candidate's Phone Number*

Candidate's IEPA Membership Number

Please provide your IEPA membership number. If you can't remember your number you can look up you membership number here: https://bit.ly/3iEg7mD

Vice President Role*

Please indicate the position you wish to be nominated

Vice President – Middle East & North Africa
Vice – Sub Saharan Africa
Vice President – Central and South America

Candidate's Bio*

Please provide a 250 word biography that we can display on our promotional materials for the election

Candidate Statement*

Please provide a Candidate Statement explaining why you would like to be part of the IEPA Board

Candidate's Photo (Headshot)*

Please provide a high quality headshot in .jpg file format that we can use for the elections

Drop files here or

Accepted file types: jpg, Max. file size: 64 MB, Max. files: 3.

Candidate's Electronic Email Signature*

Please provide your signature in .jpg or .png file format

Drop files here or

Accepted file types: jpg, png, Max. file size: 64 MB.

Nominator 1 Name*

First Last

Nominator 1 Email*

Nominator 1 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Nominator 1 IEPA Membership Number

Please provide the IEPA membership number for each Nominator. If not known you can share this link with your nominator to help locate it: https://bit.ly/3iEg7mD

Nominator 1 Electronic Email Signature*

Please provide signature for Nominator 1 in .jpg or .png file format

Drop files here or

Accepted file types: jpg, png, Max. file size: 64 MB, Max. files: 3.

Nominator 2 Name*

First Last

Nominator 2 Email*

Nominator 2 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Nominator 2 IEPA Membership Number

Please provide the IEPA membership number for each Nominator. If not known you can share this link with your nominator to help locate it: https://bit.ly/3iEg7mD

Nominator 2 Electronic Email Signature*

Please provide signature for Nominator 2 in .jpg or .png file format

Drop files here or

Accepted file types: jpg, png, Max. file size: 64 MB, Max. files: 3.

Phone

This field is for validation purposes and should be left unchanged.

Nomination Form – IEPA New Vice President Roles

Nomination Form - New IEPA Vice President Roles

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