Nomination form for Active Member for the Natural Health Products Program Advisory Committee

Section 1: Nominee Information

Prefix (Mr./Mrs./Ms./Dr.)

First Name

Last Name

Company/Organization

Department/Division

Title or designation, if applicable

Street Address

City

Province

Postal Code

Telephone

• Work
• Cellular
• Other (please specify)

Facsimile

• Work
• Other (please specify)

E-mail address

• Work
• Other (please specify)

Preferred language for future communications

• English
• French

Section 2: Nominee Areas of Representation

A. Network or Association, check all that apply

A network is defined as an "association of independent individuals, organizations and/or communities of interest whose primary purpose is forming a strong community in order to gain strength and perform as a significant player in relation to current market situations."

• National
• Provincial
• Regional
• Other (please specify)

B. Sector, check all that apply:

• Patient and Consumer Group
• Industry
• Health and Regulatory Sector
• Research/Academia
• Retail
• Other (please specify)

C. Represented Enterprise, check all that apply

• Small/Medium
• Large