Society Representative information

Please complete this first page to verify that you are qualified to represent your society and can nominate TTT candidates. (Submit candidate information on page 2.)

Name of WGO Member Society:

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* 1. Name of WGO Member Society:

Name of Society Representative submitting this form (first and surname):

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* 2. Name of Society Representative submitting this form (first and surname):

I certify that I am able to represent my society and have the authority to nominate a Train the Trainers participant(s).

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* 3. I certify that I am able to represent my society and have the authority to nominate a Train the Trainers participant(s).

Your Position in your Society:

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* 4. Your Position in your Society:

Your email address:

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* 5. Your email address:

Your second email address (optional):

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* 6. Your second email address (optional):

Your phone number:

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* 7. Your phone number:

Are you completing this form on a different Society Representative’s behalf?

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* 8. Are you completing this form on a different Society Representative’s behalf?

I understand that the society I am representing must pay their WGO membership dues through 2017 to have our nominee(s) accepted for the Train the Trainers workshop.

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* 9. I understand that the society I am representing must pay their WGO membership dues through 2017 to have our nominee(s) accepted for the Train the Trainers workshop.

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