Part I - Nominee Contact Information

Name: Address 1: Address 2: City: Province: Postal Code: Work Telephone: Home Telephone: Cellphone: Email:
 

Part II - Background Information

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

1. Education

Resume:
Institution 1
Name & Location of School or Institution: Course, Program, Major field: Credits, Diploma, Degree attained: Date Completed:

Institution 2
Name & Location of School or Institution: Course, Program, Major field: Credits, Diploma, Degree attained: Date Completed:

Institution 3
Name & Location of School or Institution: Course, Program, Major field: Credits, Diploma, Degree attained: Date Completed:
 

2. Directorships

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

Organization 1
Organization: Years Served: Position Held:
Organization 2
Organization: Years Served: Position Held:  
Organization 3
Organization: Years Served: Position Held:
Organization 4
Organization: Years Served: Position Held:
Organization 5
Organization: Years Served: Position Held:
Organization 6
Organization: Years Served: Position Held:
Organization 7
Organization: Years Served: Position Held:
Organization 8
Organization: Years Served: Position Held:
Optional - Additional board list:

3. Current or past employment

Employer 1
Organization: Position Held: Years Served:
Employer 2
Organization: Position Held: Years Served:
Employer 3
Organization: Position Held: Years Served:
Employer 4
Organization: Position Held: Years Served:

4. Membership in Professional Organizations (List)

Membership in Professional:

5. Designation, awards or other recognition (List)

Designation:

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.

Award Selection Criteria*:

Part IV - References

Name: Occupation: Address: Work Telephone: Home Telephone: Email: Upload file: Name: Occupation: Address: Work Telephone: Home Telephone: Email: Upload file: Name: Occupation: Address: Work Telephone: Home Telephone: Email: Upload file:

Part V - Nominator Contact Information

Name: Address 1: Address 2: City: Province: Postal Code: Work Telephone: Home Telephone: Cellphone: Email:

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).

Electronic Signature: Date: