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Annex B: Nomination Form
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(PDF Version - 85 K)This summary will help ensure that each nominee's potential contributions are well understood. Please submit the nominee's curriculum vitae in addition to the following requested information. This form may be completed by the nominee him/herself, or by a sponsor who wishes to recommend a nominee.
PART I - Sponsor Contact Information (if applicable)
Are you completing this form on behalf of somebody else? Yes ☐ No ☐
If yes, please provide your contact information.
First Name _____________________ Last Name _____________________
Title _________________________________________________________
Organization ___________________________________________________
Phone _______________________ Fax _____________________________
E-mail ________________________________________________________
PART II - Nominee Contact Information
First Name _____________________ Last Name _____________________
Gender: [ ] Male [ ] Female
Title _________________________________________________________
Organization ___________________________________________________
Street Address _________________________________________________
City ______________________ Prov./ Terr./State______________________
Country ______________________ Postal Code ______________________
Phone _______________________ Fax _____________________________
E-mail ________________________________________________________
Affiliation ______________________________________________________
Official languages spoken (check one or both) : [ ] French [ ] English
PART III - Rationale
Briefly explain (500 words maximum) why the nominee is a good candidate for the Challenge Advisory Panel. Please be sure to include:
- Knowledge, expertise, and experience relevant to the Panel's mandate (see Appendix A, draft Terms of Reference)
- Interest in and commitment to the work of the Panel
- Previous experience in advisory or similar committees
PART IV - Nominee's Expertise
Please place an (√) besides the area(s) that best describe the nominee's expertise and background.
| ( ) | Application of the precautionary principle as a policy instrument; |
| ( ) | Chemical policies of, and the application of the precautionary principle in, other jurisdictions; |
| ( ) | Chemical substance production, import, and/or use, and associated human health and environmental protection procedures; |
| ( ) | International and/or domestic chemical market economics; |
| ( ) | Environmental and/or human health risk study, policy, and/or communication; |
| ( ) | Environmental and/or biological sciences; |
| ( ) | Environmental health social movements in Canada; |
| ( ) | Health and Aboriginal communities; |
| ( ) | Health and safety issues in the home and workplace, especially regarding chemical substances; |
| ( ) | Health care planning and/or delivery |
PART V - References
Please provide the name and contact information for two referees.
Referee 1:
First Name _____________________ Last Name _____________________
Title _________________________________________________________
Organization ___________________________________________________
Street Address _________________________________________________
City ______________________ Prov./ Terr./State______________________
Country ______________________ Postal Code ______________________
Phone _______________________ Fax _____________________________
E-mail _______________________________________________________
Affiliation ______________________________________________________
Referee 2:
First Name _____________________ Last Name _____________________
Title _________________________________________________________
Organization ___________________________________________________
Street Address _________________________________________________
City ______________________ Prov./ Terr./State______________________
Country ______________________ Postal Code ______________________
Phone _______________________ Fax _____________________________
E-mail ________________________________________________________
Affiliation ______________________________________________________
