ELECTION NOMINATION FORM

ELECTION NOMINATION FORM
PLEASE COMPLETE APPLICATION FORM IN BLOCK LETTERS

CANDIDATE PARTICULARS (Resume must be attached to this form)
Full Name*

First NameLast Name
Account Number*
Date Joined:

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
Phone (cell) #:*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
Profession / Occupation*
Employer*
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

DECLARATION
I First Name* Last Name* agree to be a nominated person and if elected, to serve faithfully as a member of the Board of Directors / Credit / Supervisory Committee. I hereby declare that if voted in I will be bound by all the applicable policies of the Society.

I confirm that all information given herein is true and correct and if any information is deemed to be inaccurate, my selection will be null, and void and I will no longer be eligible to serve.
SIGNATURE OF NOMINEE*

Powered by Jotform SignClear
Date

DayMonthYear
Date

NOMINATION
I hereby nominate Mr. / Mrs./ Miss (tick one) First Name Last Name and declare that he/she is a fit and proper person for election to the following.
ELECTION TO THE BOARD OF DIRECTORS (for a period of three (3) years)ELECTION TO THE CREDIT COMMITTEE (for a period of one (1) year)ELECTION TO THE SUPERVISORY COMMITTEE (for a period of one (1) year)
NOMINATOR NAME*
NOMINATOR 2 NAME
ACCOUNT NUMBER
NOMINATOR 2 ACCOUNT NUMBER
NOMINATOR SIGNATURE

Powered by Jotform SignClear
Signature can be replaced with signed letter from Nominator. (see next section)
NOMINATOR 2 SIGNATURE

Powered by Jotform SignClear
Signature can be replaced with signed letter from Nominator. (see next section)
Date

MonthDayYear
Date
Date

MonthDayYear
Date

PLEASE COMPLETE APPLICATION FORM IN BLOCK LETTERS