Skip to main content

Fellowship Nomination Form

Nomination deadline date is October 19, 2023

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

*Required Fields

Part I - Nominee Contact Information


Part II - Background Information

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

1. Education

(PDF, doc, docx only)

Institution 1

Institution 2

Institution 3


2. Directorships

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

Organization 1

Organization 2
Organization 3

Organization 4

Organization 5

Organization 6

Organization 7

Organization 8

3. Current or past employment

Employer 1

Employer 2

Employer 3

Employer 4

4. Membership in Professional Organizations (List)

5. Designation, 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 do not exceed 1000 words.

Part IV - References

Part V - Nominator Contact Information


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).