Fellowship Nomination Form

2018 Nomination deadline date is November 6, 2017

Please ensure you have read the nomination guidelines before completing. 

The online form must be completed in one sesson, i.e., you cannot save and return to it later. Alternatively, you may complete and submit a fillable nomination form by email to nominations@icd.ca.
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Part I - Nominee Contact Information

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Part II - Background Information

Complete to the best of your knowledge. You are also welcome to submit a resume.

Resume 
Upload:
 (PDF, doc, docx only) 

1. Education

 
 
 
 
 
 
 
 
 
 
 
 



2. Directorships 

(If space does not permit please attach additional document below)

(e.g. Board Chair, Governance Committee Chair, Director)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Optional - Additional board list
Upload:
 (PDF, doc, docx only) 


3. Current or past employment

 
 
 
 
 
 
 
 
 
 
 
 


4. Membership in Professional Organizations (List)

 

5. Designations, awards or other recognition (List)

 


 

Part III - Award Selection Criteria

Please provide a comprehensive description of your nominees qualifications against the following selection criteria, as more fully described above:

1.    Leadership and Stewardship
2.    Accountability to Stakeholders
3.    Contributions to Governance
4.    Relationship with the CEO and Management
5.    Enhancing the Effectiveness of the Board
6.    Collegiality
 
Please cite examples that demonstrate actions/initiatives that go above and beyond what is normally expected in the boardroom. Note: Please not exceed 1000 words.
 

1. Leadership and Stewardship:

 

2. Accountability to Stakeholders:

 

3. Contributions to Governance

 

4. Relationship with the CEO and Management

 

5. Enhancing the Effectiveness of the Board

 

6. Collegiality

 

Part IV - References

The following individuals (maximum 3) support this nomination. We encourage you to submit letters of reference in support of the nominee’s application.

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 (PDF, doc, docx only) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 (PDF, doc, docx only) 

Part V - Nominator Contact Information

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Declaration

To the best of my knowledge, the information contained in this application is true and 
 (enter full name of Nominee) adheres to the principles outlined in the ICD Code of Conduct (excluding those sections that refer to ICD membership).

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(Please enter your Full Name)  

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For changes to the form after it has been submitted, please contact Denise De Masi, Manager, Designations at ddemasi@icd.ca.