Nomination Form - President Elect IEPA Elections 2024

Please complete the following details
This form must be completed and signed by two nominators as well as the candidate.

The IEPA board recognises that early intervention in mental health networks are less developed in some regions. Therefore, if you wish to stand for election, but you do not know two nominators, existing IEPA board members can fulfil this function.

Please contact the IEPA office via email to election2024@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 member number please try to look up your number here and/or email election2024@iepa.org.au

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 250 word Candidate Statement explaining why you would like to be IEPA President and 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: 128 MB, Max. files: 2.

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 please ask the nominator to try to look up their number here and/or email election2024@iepa.org.au

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: 128 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 please ask the nominator to try to look up their number here and/or email election2024@iepa.org.au

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: 128 MB, Max. files: 3.

Comments

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

Nomination Form – President Elect IEPA Elections 2024

Nomination Form - President Elect 2024 IEPA Elections

Membership

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Nomination Form – President Elect IEPA Elections 2024

Nomination Form - President Elect 2024 IEPA Elections

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