Nomination form for Elected Member before Friday 20 May 2016 The Returning Officer UTS Haberfield Club Ltd PO Box 3210 Broadway NSW 2007 Email: anne.pauli@uts.edu.au I hereby nominate for the role of Elected Member to the Board of the UTS Haberfield Club Ltd. [PLEASE COMPLETE THE FOLLOWING IN BLOCK LETTERS]:
Title:
___________
Surname: _____________________________ Given Name: __________________________
Residential Address: _____________________________________________________________________________
________________________________________________________________ Postcode: _____________________
Postal Address (if different from above): ____________________________________________________________
________________________________________________________________ Postcode: ______________________
Date of Birth: ____________________________
Age: _________
Phone: (private) _____________________ (business) _________________ (mobile) __________________________
Email: _________________________________________________________________________________________
Signature: _____________________________________________
Date: _________________________________
Proposed by:
Seconded by:
Name: _________________________________________
Name: ________________________________________
Membership No: _________________________________
Membership No: _______________________________
Signature: ______________________________________
Signature: _____________________________________