NOMINATION FORMTO SERVE ON THE CIMA SOUTH-EAST ASIA REGIONAL BOARD 2011-2014

AS AN ELECTED MEMBER

SECTION A: Nomination

We the undersigned, being members (ACMAs/FCMAs) of the Chartered Institute of Management Accountants and each having a registered addressin Indonesia do hereby nominate:

Name: (in full): ______

Please print in block letters

Date of Birth: _____/_____/ ______CIMA Contact ID number:______

(optional)DD MM YEAR

Registered address: ______

______

as a fit and proper candidate for election to the South-East Asia Regional Boardof the Chartered Institute of Management Accountants.

DETAILS OF NOMINATORS (Members only)

1 Name: (in full): ______

Please print in block letters

Registered address ______

Signature: ______CIMA Contact ID number:______

2 Name: (in full): ______

Please print in block letters

Registered address: ______

Signature: ______CIMA Contact ID number:______

3 Name: (in full): ______

Please print in block letters

Registered address ______

Signature: ______CIMA Contact ID number:______

SECTION B: Resumė

Please attach a biographical summary of the nomineeincluding achievements with CIMA as well as career achievements. This should be no longer than 200 words. If this number is exceeded a précis will be used. CIMA reserves the right to edit any electioneering statements. In the event of an election this resumė will be used for the electronic ballot paper.An up-to-date e-photo should also be supplied. Please submit the resumėby email

SECTION C: Declaration to be signed by the nominee:

I ______, the undersigned being a member of the Chartered Institute of Management Accountants and having a registered address in Indonesia, hereby confirm the foregoing particulars are correct and declare that I consent to stand as a candidate for election to the South-East Asia Regional Boardof the Institute and that I undertake to promote the interests of the Institute to the best of my ability.

In particular I undertake to:

  • attend at least the majority of meetings of the Board
  • complete any special work that may be delegated to me by the Board.

Signature: ______Date: ______

Checklist

 Form signed by three nominators

 Form signed by nominee

 Resumė (not to exceed 200 words)

 Electronic passport size photo, format Jpeg or Tif

Returning the form

On completion, this form must be returned toRegional Director, CIMA South-East Asia, CIMA, Lots 1.03B & 1.05, Level 1, KPMG Tower, 8 First Avenue, Bandar Utama, 47800 Petaling Jaya

Selangor DarulEhsan, Malaysia either by post or email(scanned original with signatures) and reach the office not later than 12.00 noon on 14 May 2011.

Forms that have been posted after the deadline will not be accepted.

Important notice:

A scanned copy of the form is acceptable, but must be followed immediately by the signed original. In order to avoid uncertainty it is recommended that, if candidates do not receive confirmation that their nomination form has been received and is being processed, they contact the Regional Director, CIMA South-East Asia directly tel: +6 (03) 7723 0330 / email:

BEFORE the closing date, to actively seek such confirmation.

Nomination form: 21 April 2011, v1