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Assembly Representative 2017-2019 Nomination Form


Closing date for nominations: 22 September 2016

Please complete all applicable sections. * Denotes a mandatory field

Please indicate for which region or SIG you wish to nominate an Assembly Representative. You may only nominate for one representative role, i.e. either your region or SIG.

Voting, Accredited Associate, Graduate, Fellows and Retired members of the below regions and SIG’s are eligible to be nominated. Members are also welcome to put themselves forward to be nominated. Non-working members are also eligible for nomination.


I'd like to nominate for the following representative role:*   

Your details


First name*

Last name*


House number/house name*


Address 2


Address 3





Preferred telephone*

Mobile telephone

Home telephone

CIEH Membership details

CIEH Membership #  


CIEH Membership category 


Reason for nomination

Why do you want nominate this candidate/why do you want to be an Assembly Representative?

Please provide a brief description on how you/this candidate fulfils the person specification.

Please state:

  1. Candidate professional background
  2. Statement of why you/or this candidate should be elected
  3. Candidate specialist interests and experience
  4. Any contributions to the environmental health profession and CIEH membership that the candidate can offer

This information will be used as a manifesto should a ballot be required.

Please note there is a 300 word limit; longer submissions will be truncated. 


Nominee's Photograph


Attachment process 

1. Use the Browse button to locate the file that you wish to attach.
2. File extension - allowed extensions are: jpgpng.
3. When you have selected your file click on the Upload button.
4. When your file has been uploaded, click Done.
5. Please make sure you click Submit at the bottom of this form when you are ready to send your application.

Data protection consent

In accordance with the Data Protection Act 1998, the information provided on this form will be used in the election process and may be disclosed to all those who need to see it. It will also form the basis of the confidential personnel record of the successful candidate. In the case of unsuccessful candidates the information will be destroyed after twelve months. In addition, it will be held on a database and used for equal opportunities monitoring purposes.

Conflicts of interest

Have you, or any organisation you are a member of, represent, or have a pecuniary interest in, ever been a beneficiary of the CIEH?


Have you, a family member, or your employer, undertaken work for or supplied goods or services to the CIEH? (If yes, give details)


Please list any other potential conflicts of interest that you are aware of:
(Note: conflicts of interest will not necessarily prevent you from being an Assembly representative)  


Agreement & Declaration of willingness to be nominated

I confirm that I do not object to the information collected on this form being transferred onto computer for the purpose of anonymous statistical reporting, in accordance with statutory requirements and for the basis of compiling correspondence and to assist the CIEH in equal opportunities monitoring in respect of nominations. 

I agree that the CIEH has the right to validate any of the information provided. 

I declare that the information supplied on this nomination form is true and accurate. 



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