CSSANZ COUNCIL ELECTIONS

2026–2028

Nomination Form

Nominations are now open for election to the Council of the Colorectal Surgical Society of Australia and New Zealand (CSSANZ) for the 2026–2028 term.

A financial Ordinary, Foundation or Life Member, or Fellow of the Society, may nominate themselves for election to Council.

As part of the nomination process, nominees are required to provide the names of two financial CSSANZ Members who support their nomination.

If the number of nominations received exceeds the number of available Council positions, an election process will be conducted and members will be asked to vote.

The nominee profile information provided within this form may be shared with CSSANZ members to assist them in making informed voting decisions.

Nomination Deadline: Friday 31 July 2026 5pm AEST

IMPORTANT

STRONGLY RECOMMENDED: Sign in (or create an account) with Jotform using your Google, Microsoft, Facebook, or Apple account — or create a standalone Jotform account using your email address. This will allow you to save your progress and complete the form over multiple sessions.
NOTE: If you DO NOT sign in to Jotform, you will need to complete the form in one sitting. Closing the form may result in loss of any entered information.

Your Name

First NameLast Name
Your Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Your Email
example@example.com
RACS ID
For CSSANZ Office Use ONLY
AHPRA/MCNZ Number
For CSSANZ Office Use ONLY
Director Identification Number
https://www.abrs.gov.au/director-identification-number
ORCID
https://orcid.org/
Have you submitted an Expression of Interest for the CSSANZ Foundation, ANZTBCRS, or BCCA/BCCOR Boards, or do you currently hold a position on any of these Boards?

Yes - please advise which Boards:
Nominee Declaration and Consent

Before proceeding with this nomination, nominees must acknowledge the following:
I acknowledge and consent to CSSANZ undertaking verification and probity checks relevant to this nomination, including searches of professional registration, director eligibility, insolvency, and charity governance records in Australia and New Zealand.
I understand that progression of my nomination may be subject to the outcome of these checks.
Colorectal Surgical Society of Australia and New Zealand | ABN: 75 055 544 664

Supporters of Nomination

Please provide the details of two financial CSSANZ Members who support your nomination for election to the CSSANZ Council.
Supporter 1 - Full Name

First NameLast Name
Supporter 1 - Email
example@example.com
Supporter 2 - Full Name

First NameLast Name
Supporter 2 - Email
example@example.com
Colorectal Surgical Society of Australia and New Zealand | ABN: 75 055 544 664

Nominee Profile

For Distribution to CSSANZ Members if an Election is Required.
To assist members in making informed voting decisions, the nominee profile information will be shared with CSSANZ members as part of the election process. By proceeding, you acknowledge and consent to this information being distributed for that purpose.
Current Position(s) (e.g. Head of Unit at Waikato Hospital):
**You can list multiple current positions
Your strengths and suitability for a position on the CSSANZ Council:
**TIP: A short paragraph is preferred
Your thoughts on the future direction of the CSSANZ:
**TIP: A short paragraph is preferred
CSSANZ Community Involvement: List your involvement with CSSANZ, including any positions held, committees served on, or activities/projects contributed to:
**TIP: Dot points are preferred
Other Roles: List ANY other boards, committees, or organisations you are affiliated with and what your ROLE is (e.g. RACS General Surgery Fellowship - Examiner, 2022). Both medical and non-medical roles may be included:
**TIP: Dot points are preferred
Additional Qualifications (e.g. Grad Dip of Business Management; AICD - Australian Institute of Company Directors, 2023):
**TIP: Dot points are preferred
Upload Your CV:

**PDF format preferred
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Upload a clear, suitably professional (looking) head and shoulders photo:

**Mobile phone photos are suitable quality
Cancelof
Colorectal Surgical Society of Australia and New Zealand | ABN: 75 055 544 664

Nominee Declaration and Consent

I, {yourName}, confirm that I am nominating for election to the CSSANZ Council for the 2026–2028 term.

I acknowledge and consent to CSSANZ undertaking verification and probity checks relevant to this application, including searches of professional registration, director eligibility, insolvency, and charity governance records in Australia and New Zealand.

{iAcknowledge}

I understand that progression of my application may be subject to the outcome of these checks.

{iUnderstand}

Nominee Profile

To assist members in making informed voting decisions, nominee profile information provided within this form may be distributed to CSSANZ members as part of the election process.

By proceeding, you acknowledge and consent to this information being shared for that purpose.

{toAssist}
Signature
Date

DayMonthYear
Date
Unable to Proceed

Dear {yourName},

Thank you for your interest in nominating for election to the CSSANZ Council.

I acknowledge and consent to CSSANZ undertaking verification and probity checks relevant to this nomination, including searches of professional registration, director eligibility, insolvency, and charity governance records in Australia and New Zealand.

Response provided: {iAcknowledge}

I understand that progression of my nomination may be subject to the outcome of these checks.

Response provided: {iUnderstand}

As acknowledgement of the declaration and consent requirements is mandatory for all nominees, you are unable to proceed with your nomination at this time.

If you believe this is in error, please contact the CSSANZ Office.

CSSANZ Office
e: cssanz@cssanz.org
Not Eligible

Dear {yourName},

Based on your responses, you are currently not eligible to nominate for CSSANZ Council.

As consent for the distribution of nominee profile information was not provided, you are not eligible to proceed with the nomination process.

CSSANZ Office
e: cssanz@cssanz.org
Colorectal Surgical Society of Australia and New Zealand | ABN: 75 055 544 664
Should be Empty:

CSSANZ COUNCIL ELECTIONS

Nomination Form

Nominee Declaration and Consent

Supporters of Nomination

Nominee Profile

About You

Clinical Privileges

Director Eligibility and Consent

Nominee Declaration and Consent

Nominee Profile

Unable to Proceed

Not Eligible