Expression of Interest to be on the NSCMLT Board of Directors Form

First Name(*)

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Last Name(*)

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Phone (123-456-7890)(*)

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Email(*)

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NSCMLT License Number(*)

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MLT License Class - Please select one(*)

MLT General MLT Diagnostic Cytology MLT Clinical Genetics

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Employer(*)

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Please provide an explanation of why you are interested in serving as a NSCMLT board member

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Nominee Profile(*)

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Nominee's Consent(*)

I agree to allow my name to stand for election to the position on the Board of Directors. If elected, I pledge to uphold the Act and Regulations as outlined in the Act of the NSCMLT, and carry out the duties and responsibilities of the office and such additional duties as may be assigned during my term to the best of my ability.

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Nominee's Consent(*)

I am a member of NSCMLT in good standing.

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Practising License(*)

Holds a practising licence or a conditional licence and is not a temporary license holder.

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Note: NSCMLT provides a remuneration and applicable expenses for this voluntary position. Most NSCMLT meetings are held virtually every other month on a Monday, Tuesday or Wednesday evening for approximately 2 hours.

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Expression of Interest to be on the NSCMLT Board of Directors Form

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