Vote 18
2018 Medical Council of New Zealand Election
NOMINATION PAPER A - NOMINATORS to fill out
We the undersigned registered medical practitioners nominate (please print full name legibly):
for nomination to the Medical Council of New Zealand. Signatures, names and registration numbers must all be on the same form and legible for the nomination to be accepted. Name of 1st nominator: Signature of 1st nominator:
MCNZ registration number:
Name of 2nd nominator: Signature of 2nd nominator:
MCNZ registration number:
Name of 3rd nominator: Signature of 3rd nominator:
MCNZ registration number:
Name of 4th nominator: Signature of 4th nominator:
MCNZ registration number:
Name of 5th nominator: Signature of 5th nominator:
MCNZ registration number:
B - CANDIDATE to fill out - IMPORTANT INFORMATION ON REVERSE I, (please print full name legibly): of, (registered address:
I am willing to stand for election and, if appointed by the Minister, to assume all duties of a member of the Medical Council of New Zealand. Registration number:
MCNZ registration number:
Signature of Candidate:
Date:
D D M M Y Y
The nomination paper along with the profile statement and photo must be in the hands of the Returning Officer no later than:
12 noon on Friday, 19 January 2018
Scan your nomination paper and attach with your statement and photo (see reverse for details) to an email and send to:
[email protected] The Returning Officer does not recommend posting any nomination documents, if you are unable to email the required documents please contact the Returning Officer on the Election Helpline for advice.
0800 666 029
CANDIDATE to fill out - Biographical sketch Maximum 100 words Please note: all information provided on this form will be circulated (and if necessary edited to comply with format) with the voting papers to all voters. Personal details (please print legibly) Name: Address/location of practice: Phone number (where voters can contact you if they wish): Email address (where voters can contact you if they wish): Medical qualifications Institution: Date: Institution: Date: Institution: Date: Registration status (ie, general scope, vocational scope)
Practising certificate status Please tick one:
Current
Not current
Principal branch(es) of medicine in which you currently practise (eg, general practice, obstetrics and gynaecology)
Current appointment(s)
Disclosure of criminal conviction, professional disciplinary proceeding or inquiry Please provide details of any of the following. • Criminal conviction and/or discharge without conviction in criminal proceedings • Current criminal investigation or proceedings • Past adverse finding by the Health Practitioners Disciplinary Committee • A guilty finding in any criminal proceeding • A current disciplinary proceeding before the Health Practitioners Disciplinary Tribunal • A current enquiry into the competence or health of a nominee by the Medical Council, an employer or a professional body • A current complaint investigation by the Medical Council, the Health and Disability Commissioner, an employer or a professional body • Any restrictions or conditions on practice
CANDIDATE to read - STATEMENT TO VOTERS Please save your brief statement to voters (maximum 100 words, strictly enforced) as a Microsoft Word document, a jpg digital camera image of yourself (high resolution, head and shoulders only) and a scan of both sides of this nomination paper, then attach and email to the Returning Officer with your full name and registration number. The nomination paper along with the profile statement and photo must be in the hands of the Returning Officer no later than: 12 noon on Friday, 19 January 2018.
Scan and email to:
[email protected] The Returning Officer does not recommend posting any nomination documents, if you are unable to email the required documents please contact the Returning Officer on the Election Helpline for advice.
