Zunmo Nomination Form

ZAMBIA UNION OF NURSES AND MIDWIVES ORGANISATION
ELECTION NOMINATION FORM
Section A: (To be completed by nominee)
Surname: Mr/Ms/Mrs/Dr: ………………………. Forename(s): …………………………….
NRC No: ……………………… Sex: ………………… Nationality: …………………………….
Date of Birth: ...........….…………. Name of Employer: …………………….. ………………….
Job Title: …………………………………………Date of Appointment: ……………………….
Employment No: .…………………………………. NMCZ No: ……………………………….
Year joined ZUNMO: ………………………… ZUNMO No (if known): …………….………
Your current ZUNO Branch: ………………………………………….
District: ………………………………………... Province: ………………………………………
Do you have any pending disciplinary case(s) at ZUNMO/NMCZ/Police/Court or with
your employer? …………………………...
If yes, state the type of offence: ………………………………………………………………..
ZUNMO POSITION BEING APPLIED FOR
I wish to apply to contest for the position of: ……………………………………………...
1
Type of committee: …………………………………………………………………………….
PROFESSIONAL QUALIFICATIONS
Qualification Name of Institute Examining Body Date of qualification
Basic
Post Basic
Other qualifications different

from Nursing (if any)
2
Previous responsibilities (post) held in ZUNMO and any other Non-Governmental
Organizations (if any):
Years
Title/Post Name of Organization Branch Institution From To
DECLARATION:
I …………………………………………………….. hereby declare that the above

information is true to the best of my knowledge.
Signature of Candidate: ………………………………… Date: …………………………….
3
Section B: (To be completed by proposer – a delegate from the aspiring candidate’s
branch)
Name of NMCZ No. ZUNMO Year Joined Present Signature

Proposer Card No. ZUNMO Branch
Section C:
APPROVED BY: ………………………………………………………. Branch Chairperson

(Full Names)
Signature: ………………………………… Date: ……………………………………………
Certified by: ……………………………………………………… Provincial Representative

(Full Names)
Signature: ……………………………….. Date: ……………………………………………..
Section D: (For office use only – to be completed by the Election Adhoc Committee
Chairperson/Secretary)
After strict examination of the nominee’s credentials, ZUNMO membership card/receipts

and other relevant documents, I wish to confirm my satisfaction and hereby
RECOMMEND to the Returning Officer from the Ministry of Labour, Youth and Sports
that the under mentions do*/do not* qualify to apply for the applied for ZUNMO
Position:
Mr/Mrs/Ms/Dr/Prof: ……………………………………………………………………………
……………………………………………………………………………………………………..
4
REASONS FOR NOT RECOMMEDING
Mr/Mrs/Ms/Dr/Prof: …………………………………………………………………………….
As a candidate in this year’s ZUNMO elections are as below:
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
………………………………………………………………………………………………………
Name and signature of the Elections’ Adhoc Committee Chairperson
……………………………………………………………………………………………………….
Date: ………………………………………………………………………………………………..
Witness (Elections Adhoc Committee Member) Name and Signature:
………………………………………………………………………………………………………
Date: ……………………………………………………………………………………………….

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ZAMBIA UNION OF NURSES AND MIDWIVES ORGANISATION

ELECTION NOMINATION FORM

Section A: (To be completed by nominee)

Surname: Mr/Ms/Mrs/Dr: ………………………. Forename(s): …………………………….

NRC No: ……………………… Sex: ………………… Nationality: …………………………….

Date of Birth: ...........….…………. Name of Employer: …………………….. ………………….

Job Title: …………………………………………Date of Appointment: ……………………….

Employment No: .…………………………………. NMCZ No: ……………………………….

Year joined ZUNMO: ………………………… ZUNMO No (if known): …………….………

Your current ZUNO Branch: ………………………………………….

District: ………………………………………... Province: ………………………………………

Do you have any pending disciplinary case(s) at ZUNMO/NMCZ/Police/Court or with

your employer? …………………………...

If yes, state the type of offence: ………………………………………………………………..

ZUNMO POSITION BEING APPLIED FOR

I wish to apply to contest for the position of: ……………………………………………...

Qualification Name of Institute Examining Body Date of qualification

Other qualifications different

I …………………………………………………….. hereby declare that the above

Signature of Candidate: ………………………………… Date: …………………………….

Name of NMCZ No. ZUNMO Year Joined Present Signature

APPROVED BY: ………………………………………………………. Branch Chairperson

Signature: ………………………………… Date: ……………………………………………

Certified by: ……………………………………………………… Provincial Representative

Signature: ……………………………….. Date: ……………………………………………..

After strict examination of the nominee’s credentials, ZUNMO membership card/receipts

As a candidate in this year’s ZUNMO elections are as below:

Name and signature of the Elections’ Adhoc Committee Chairperson

Witness (Elections Adhoc Committee Member) Name and Signature:

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