Nomination Form for Hampshire and IOW LDC

NOMINATION FORM

FOR CANDIDATE TO STAND FOR ELECTION TO

THE HAMPSHIRE & ISLE OF WIGHT LOCAL

DENTAL COMMITTEE

I wish to put myself forward as a member of the Hampshire and Isle of Wight Local Dental Committee. I am an eligible performer engaged in the provision of NHS Primary Dental Care Services within the Hampshire and the IOW constituency.

 

Name:………………………………………………………………………………

Address:………………………………………………………………………….

……………………………………………………………………………………….

……………………………………………………………………………………….

Tel No/email…………………………………………………………………..

Signed…………………………………………………………………………….

 

Proposed by:…………………………………………………………………..

Signed:……………………………………………………………………………

Seconded by:…………………………………………………………………..

Signed:……………………………………………………………………………

Signatories must be eligible practitioners/performers

Please send to the Returning Officer:

Mrs Emily Vidovic,

By the 17^th June 2021 (the closing date for nominations)

H&IOW LDC NOMINATION FORM 2021