Nomination Form for Elected Member

Page 1

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: _____________________________________



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