Council Elections - Confirmation of Eligibility Form

 

Please insert the Nomination Tracking Number that was provided to you following the submission of your Expression of Interest in being nominated.

 

Please enter your first name.

 

Please enter your last name.

 

Please enter your Registration Number with the College of Naturopaths of Ontario

 

Please enter your email address.

 

Please select the Electoral District in which you are presently seeking nomination.

 

 

Confirmation

Please review each of the following questions carefully and respond by indicating Yes or No.

 

Do you presently, or will you by the date that the call for nominations close, hold a valid Certificate of Registration with the College of Naturopaths of Ontario?

 

Please indicate which type of Certificate of Registration you presently or will hold by the date that the call for nominations closes.

 

Are you presently in default of payment of any fees owed to the College?

 

Are you presently in default of returning any requested information to the College?

 

Are you currently the subject of a current professional misconduct or incompetence matter that has been referred to the Discipline Committee or are you currently the subject of an incapacity matter referred to the Fitness to Practise Committee of this College or any other regulatory authority?

 

Has your Certificate of Registration been revoked or suspended by the Discipline Committee of Fitness to Practice Committee of College of Naturopaths of Ontario in the preceding six years? Please note that administrative suspensions (non-payment of fees or failure to provide information) are not applicable.

 

Are there currently any terms, conditions or limitations applied to your Certificate of Registration by the Discipline Committee or Fitness to Practise Committee.

 

Do you agree to resign, before taking office, any responsible position, including but not necessarily limited to director, owner, board member, officer or employee, that I hold with a professional association relating to naturopathy?

 

Do you agree to resign, before taking office, any responsible position, including but not necessarily limited to director, owner, board member, or officer, that I hold with an educational institution relating to naturopathy?

 

Have you been disqualified from the Council or a Committee of the College in the preceding three years?

 

Are you currently a Council member of another regulatory College established under the Regulated Health Professions Act, 1991?

 

Are you currently an employee of the College of Naturopaths of Ontario? Please note, individuals who volunteer time with the College and who are paid a per diem are not considered employees for the purposes of this form.

 

Do you agree that, to the best of your knowledge, you do not have any other conflict of interest in serving as a Council member and do you agree to remove any such conflict of interest before taking office?

 

Have you read and complied with the Election Handbook and agree that you will do so throughout the election process?

 

 

Declaration and Signature

 

Declaration


The information that I have provided on this form is complete and accurate to the best of my abilities.

 

Signature


By checking the box below, you are affixing a signature to this form and indicating that this form and the information contained herein is bound directly to you.

 

Submission Copy

Below is a check box to receive a copy of your submission. It is highly recommended that you check this box and enter your e-mail address for a second time. This will enable the on-line system to send you a copy of the information that you have provided to the College.