Position Applied For: Chairperson Member

Name of Nominee:

Title/Designation:

Institution/Organization:

Address:

Email:

Phone Number:

Type of Nomination: Self-Nomination Peer Nomination

If Peer Nomination, Name of Nominator:

Nominator's Title/Designation:

Nominator's Contact Information - Email:

Nominator's Contact Information - Phone:

1. Briefly describe the nominee’s qualifications and experience relevant to this role:

2. Describe the nominee’s previous experience with ethical committees, research, or similar roles (if applicable):

3. Attach the following documents to this form (if applicable): Curriculum Vitae (CV) Statement of Intent (for self-nominations) or Recommendation Letter (for peer nominations) Supporting Documents (e.g., certifications, evidence of prior service)

Please describe your vision and goals for serving on the Ethics Committee (max 250 words):

I hereby declare that all the information provided in this form is accurate and true to the best of my knowledge. I understand that any false information may result in the withdrawal of my nomination.

Date:

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