Board Nomination Form

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number (Home)

Please enter a valid phone number.Format: (000) 000-0000.

Phone Number (Work)

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Education

Employment/Position

Organization

Previous experience (if any) with IPAC

Please indicate any of the following skills or experience that the candidate possesses.

Does the candidate have governmental or institutional experience?

Diversity Self-Identification

A. Gender Identity: For the purposes of this question Gender Identity refers to one's self-identified gender or the gender that one feels and or expresses, rather than birth-assigned sex. Gender may change over time.

Note regarding language: Language, particularly in relation to sexual orientation, gender identity and gender expression, involves social constructs which evolve over time. The definitions below are not meant to label individuals.

Select the option that you identify with.

B. Aboriginal and/or Indigenous Peoples: In accordance with Statistics Canada and the Canada Employment Equity Act, "Aboriginal" is defined by the Government of Canada as First Nations (Status, Non-Status, Treaty), Métis, or Inuit, and was established by the federal government as an umbrella term for diverse Indigenous peoples in Canada. For the purposes of this question an Aboriginal person is a North American Indian or a member of a First Nation, a Métis, or Inuit. North American Indians or members of a First Nation include status, treaty or registered Indians, as well as non-status and non-registered Indians. The term ‘Aboriginal’ is used in legislation and in international definitions. Indigenous Peoples may self-identify as such or may be defined by their own relations to their communities.

Do you identify as Aboriginal and/or Indigenous?

C. Visible Minority: Visible minority refers to whether a person belongs to a visible minority group. In this case visible minority is defined as persons, other than Aboriginal peoples, who are non-Caucasian in race or non-white in colour, regardless of their place of birth or citizenship.

Do you identify as a member of a visible minority in Canada?

D. Person with a Disability: People with disabilities (including invisible and episodic disabilities) is a person who has a long-term or chronic physical, mental, sensory, cognitive, intellectual, learning impairment or functional limitation (for the purposes of this question “long-term” is defined as lasting more than six months) and:

Who considers themselves to be disadvantaged in effective participation in society by reason of that impairment, or
Who believes that an employer or potential employer is likely to consider them to be disadvantaged in employment by reason of that impairment;

Do you identify as a person with a disability?

Affiliations or organizations the candidate belongs to (e.g., membership, professional, civic).

How do you feel IPAC would benefit from your involvement on the Board?

Please tell us anything else you’d like to share.

Submitted by:

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Has the candidate been contacted and agreed:

Does the candidate’s home organization support the nomination?

Thank you for your nomination

Board Nomination Form

Candidate Information

If Nominator: