South Western Substance Use Regional Forum (SURF) Nomination Form

Kildare PPN are currently seeking nominations for a number of seats on the South Western Substance Use Regional Forum (SURF). Please fill out the form below to submit a nomination on behalf of your organisation.

Closing date for nominations is 5:00pm Wednesday the 5th of February.

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* 1. Please choose the appropriate Municipal District

Athy

Celbridge / Leixlip

Clane / Maynooth

Kildare / Newbridge

Naas

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* 2. Nominating Organisation

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* 3. Details of Nominee

Name *

Address

Email Address *

Phone Number

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* 4. Candidate Statement (Maximum 150 words). This will be circulated to member groups ahead of the election . Please state why you may be the most suitable candidate for the role.

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* 5. Upload Image/Headshot

(Optional) The image supplied will be included in the voting ballot

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 6. This nomination must be authorised by the nominee’s organisation. The Authorised Officer should be the organisation’s Chairperson or Secretary. Please provide the contact email address of the group's Chairperson or Secretary for verification of nomination

Name

Position

Email Address

Phone Number

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* 7. The information provided in this form will be held by the Kildare Public Participation Network. View Kildare PPN's Private Policy here to see how your data is processed: https://bit.ly/3n6zGnX

I Consent