NATIONAL HEALTH

STUDENTS ASSOCIATION
OF GHANA
NOMINATION FORM FOR 2015 ELECTION

NAHSAG
ELECTORAL COMMISSION | nahsag.gh@gmail.com

NATIONAL HEALTH STUDENTS ASSOCIATION OF GHANA

(NAHSAG)
NOMINATION FOR NATIONAL OFFICE

2015 ELECTION
Please fix a
passport photo
here.

SECTION A NOMINEES BACKGROUND INFORMATION

(Complete all questions to validate forms)

1. Name as it appears on your documents.

(Surname):.(Other Names): Gender .
2. Date of Birth. 3. Any disability(s): Yes[ ] No[ ]
If Yes, state disability.
4. Place of Birth (Village/Town/City/District/Region) .
5. Nationality

6. .Hometown (Village/Town/City/District/Region)
..
10. Postal Address

7. Telephone/Mobile No.
..

11. Permanent Home Address (where you reside)

12. E-mail address

13. Name of Current Institution/Institution Attended

14. Address:.
...

15. Academic Program of study (Please Specify HND, BSc, PhD,

etc.).

16. ID No:
.

17. Year of admission

19
. Level of Study

18. Year of admission

20. Executive Position Sought: ..

21. Reasons for seeking Position ..

1|P

age

SECTION B OTHER INFORMATION

22. Please provide the following information of parent(s)/guardian(s) (1-4) and Next of Kin (5)
Full Name
How are you related
Telephone Number
1.
2.
3.
4.
5.

SECTION C NOMINEES EMPLOYMENT DETAILS (if applicable)

23. Name, Address and Contact information of
current or last employer

25. Year of Employment

Will you be working while you hold

office?
Yes. No

24. What are/were your main responsibilities

.

26. Year of termination

27. Period of employment

How relevant will your skills be to NAHSAG

..
..

SECTION D NOMINEES ATTENDANCE TO SEMINARS (if applicable)

28.
THEME FOR SEMINAR

ORGANIZERS OF THE SEMINAR

YEAR

1.
2.
3.
4.
5.
6.

2|P

age

SECTION E NOMINEES LEADERSHIP HISTORY (if applicable)

29.
POSITION

INSTITUTION/ORGANIZATION

PERIOD

1.
2.
3.
4.
5.
6.

SECTION F ENDORSEMENT BY NOMINEES NMA/BLOC EXECUTIVES

(NMA PRESIDENT AND ANY OTHER EXECUTIVE)

I/We, the undersigned president(s) believe that

merits consideration as ... and do hereby support
his/her nomination. I/We believe that he/she is an excellent character and in my/our opinion he/she will
become of distinct benefit to this noble association.
30.
FULL NAME AND POSITION

INSTITUTION/ASSOCIATION

SIGNATURE &
STAMP

1.
2.

3|P

age

SECTION G ENDORSEMENT BY FIVE (5) NMA or BLOC PRESIDENTS

(MUST BE FROM DIFFERENT INSTITUTIONS EXCLUDING NOMINEES NMA/BLOC PRESIDENT)

I/We, the undersigned president(s) believe that

merits consideration as ... and do hereby support
his/her nomination. I/We believe that he/she is an excellent character and in my/our opinion he/she will
become of distinct benefit to this noble association.
31.
FULL NAME

INSTITUTION/ASSOCIATION

SIGNATURE

1.
2.

3.
4.
5.

SECTION H VISION, MISSION AND ACTION PLAN(S) FOR NAHSAG

Nominee is required to list his/her plan(s) of action that will benefit NAHSAG

32. VISION STATEMENT:

..

33. MISSION STATEMENT:

a. ..
.
b.
.
c. ..
..

4|P

age

34. ACTION PLAN(S)

ACTION PLAN

BENEFIT(S) TO NAHSAG

SECTION I NOTICE TO APPLICANT (herein referred to as the nominee)

1) Applicant is to attach to this form the following documents:
a. An introductory letter from the applicants institution
b. Two (2) passport sized pictures endorsed by a person of high standing in his/her

society
c. Applicants resume with Academic Transcript which shall include at least a

semester of the recent academic year

2) This form must reach the NAHSAG vetting/electoral committee before the deadline.
3) All information provided by applicant will be verified and where such information is found to be

inconsistent with that provided by the applicant, sanctions spelt out in SECTION J of this document will
be applied to the letter.

5|P

age

SECTION J DECLARATION TO BE SIGNED BY NOMINEE

Attestation
The above information I have provided is to the best of my knowledge and belief, true and accurate and I
consent
to
my
name
being
put
forward
as
a
nominee
for
the
position
of........................................................................................................
I authorise NAHSAG Vetting/Electoral Committee to take any reasonable steps it deems necessary to
corroborate the information I have provided. I agree to abide by the rules of campaign/elections as defined by
the NAHSAG Vetting/Electoral Committee.
I agree that NAHSAG Vetting/Electoral Committee reserves the right to approach my institution or any other
appropriate body to check the authenticity of my declarations, my candidacy, proposers and/or seconders; and
to make a decision on my eligibility based on the NAHSAG Constitution and the decisions of the
Vetting/Electoral Committee.
Date: ..

Signature of nominee: .............................

Note: It is important that nominees eligibility for national office be based upon accurate information. Hence,
misrepresentation in any form or manner shall render this nomination null and void. NAHSAG
Vetting/Electoral Committee reserves the right to cancel the nominees application if false or incorrect
information is supplied without prejudice to any provision in the NAHSAG constitution.
If you have any queries or need more information, contact 0242572556/0543232506
To be deemed as a completed nomination form, all parts of the form must be filled in, all attachments added
(introductory letter from your institution, two (2) passport photos & Resume with Transcript) and
this form must be submitted before the dead line.

FOR OFFICE USE ONLY

I, the undersigned, do hereby declare that, at the close of the nomination, the nomination form of the nominee
referred to in Section A of this form had been presented and received by me.

Tick as appropriate (if received)

1. Introductory letter from institution
2. Academic Transcript
3. Resume
4. Endorsed passport sized picture

Yes [ ] No [ ]
Yes [ ] No [ ]
Yes [ ] No [ ]
Yes [ ] No [ ]

Time Date Name of recipient ..

Signature.

6|P

age

United for Health

We wish you the best of luck!!

7|P

age