Nomination Form for Employee Representatives for PIPSC
Committee on Occupational Safety and Health (COSH)
The following PIPSC Regular Members nominate
Candidate’s Name (Printed):
As employee representative / employee co-chair for PIPSC to the Committee on Occupational Safety and Health (COSH) at :
Name of Research Center, Program or Branch (Printed) :
Name (Printed) / PIPSC Membership No. / Building & Phone No. / Signature and Date
I, __ , hereby accept the nomination.
Candidate’s Name (printed)
The completed nomination form must be sent to the administrative assistant responsible for the NRC RO/RCO Group by emailing it to the PIPSC at firstname.lastname@example.org.
Candidate and nominators must be members of PIPSC. All nominations will need to be approved by the NRC RO/RCO, IS or LS Group Executive depending on the classification of the candidate.