Candidate Confirmation Form

Candidate Confirmation Form

I, the undersigned, being a current HSG Member, accept my nomination as a candidate for the HSG Board membership and confirm that:

I have read, and I understand, the document entitled “HSG Board Member Election Policy and Procedures”, I fully understand eligibility requirements for the nominated Board candidates stated in this policy and, by submitting this form I hereby confirm that I am in full compliance with the stated HSG policy;

I have read, and I understand, the document entitled "Roles and Responsibilities of the HSG Board and its member" and I am fully prepared to dedicate my time and knowledge to the benefit of the society - HSG;

I understand that, in order to validate my nomination, and per Article 7 of the stated policy, I am submitting this confirmation form via e-mail and prior to the deadline to the HSG Secretariat (e-mail ) and provided set of documents include (please mark all documents that are relevant):

This Candidate Confirmation Form

My brief personal history with 150-word summary and 2-3 (two-three) page long more elaborate personal history

My digital photo

My statement why I am interested to become a board member and how I can contribute to HSG and its mission

I hereby confirm, that I am a national and/or resident in the region (please mark appropriate)

☐Africa

☐The Americas

☐Eastern Mediterranean

☐Europe

☐South-East Asia

☐Western Pacific

IfI will be considered for a regional seat on the HSG board, I confirm that I have strong record accomplishment in the health system related work in the region. And in order to validate my nomination, and per Article 7 of the stated policy, I will submit additionally:

Scanned copy of my passport and/or residence permit

Evidence of a strong record of accomplishment in my region, by working on health system issues.

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SignaturePrint Name

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Print Date

Please attach all documents listed in this form and which are relevant

Please NOTE later and/or incomplete submissions will be disqualified