Nomination Form – IEPA New Vice President Roles

Nomination Form - New IEPA 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.
Candidate's Electronic Email Signature*
Please provide your signature in .jpg or .png file format
Drop files here or

Accepted file types: jpg, png.
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.
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.
Phone
This field is for validation purposes and should be left unchanged.

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Nomination Form – IEPA New Vice President Roles

Nomination Form - New IEPA Vice President Roles

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