Nominator:
__________________________________________
__________________________________________
Name (print)
Signature
__________________________________________
__________________________________________
Date
Fax number
__________________________________________ Address
____________________________________
Email
_______________________________________
_______________________________________
I, ___________________________________________________,
accept this nomination
Candidate's statement (max. 50 words): ______________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Nominee:
_________________________________________
________________________________________
Name (print)
Signature
__________________________________________
________________________________________
Date
Fax number
__________________________________________
Address _________________________________
Email
________________________________________
________________________________________
Return this form by mail or fax to Bart Preneel
(See previous page for address and deadline.)