Nomination Form

Nomination for the position of:

Candidate proposed:

If elected, I hereby agree to serve:
YesNo

Date:

Name of Adhering Body:

Name of Nominator:

Position of the nominator:

BIOGRAPHICAL DETAILS OF CANDIDATE NOMINATED

Current appointment:

Postal Address:

Email Address:

Date of Birth:

University Qualification:

Professional Positions (with dates over the past 10 years):

Professional Memberships and/or Awards:

Activities on behalf of IUPAB:

Personal Statement with other Relevant Information:

Please do not supply any additional material