ISA KERALA STATE CHAPTER
ELECTION 2021 -2022
Nomination form

 

1. Name of Candidate :
2. ISA Membership Number :
3. Date & year of Joining ISA :
4. Post for which nomination is filed :
5. ISA KSC Annual conferences attended in last 5 years :
Proposed by
Name…………………….…………………………………………… ISA Membership No………………….

 

Seconded By

Signature ……………………………………………………………………

Name ………………………………………………………………..ISA Membership No…………..……..

Signature…………………………………………………………………….

I, Dr… hereby give my consent to contest for the post of
……………………………………………………………………………… during the ISA-KSC elections-2021 to be held on Sunday, 12th December 2021 at 12.00 noon at Hotel Horizon, Aristo Road, Thampanoor, Thiruvananthapuram, the venue of ISACON KERALA 2021. I have gone through the rules and regulations as per article X1 of the constitution of ISA-KSC regarding qualification, eligibility and procedure of election and affirm that I fulfill the eligibility criteria required to contest the post.

Signature of the Candidate....................................... Mob No. ……………………............

Address ……………………………………………………………………………………………………..
……………………………………………………………………………………………………..

As per article XI-5 of the constitution of ISA-KSC, completed nomination form should be send to the Hon. Secretary under registered cover or hand delivery and a receipt obtained, so as to reach Hon. Secretary not later than the last post on the final day of nomination(12-11-2021). Fee details-(for the post of President elect)
Amount…………………………… DD/At par Cheque No…………………………… Bank....................................................
Branch…………………………………………………………… Dated………………………

Received on Date Time Received by Signature Valid on scrutiny…………… Invalid on scrutiny………….

Dr. Binil Isaac Mathew, Hon Secretary & Returning officer, ISA KSC
Cardiac Anaesthesiologist, Jubilee Hrudayalaya, JMMC, Jubilee Mission P.O. Thrissur, Pin 680005. www.isakerala.org, Email: This email address is being protected from spambots. You need JavaScript enabled to view it. , Mob. 9744850222