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01. Nature of position being applied for (see the attached list for reference):

BUREAU (Please specify hereafter)

COMMITTEES (Please specify hereafter)

PANELS (Please specify hereafter)

02. Title: Mr. Mrs. Ms. Dr. Other

03. First Name:

04. Last Name:

05. Date of Birth: (dd/mm/yyyy)

06. Citizenship*: 07. Civil Status:

08. Contact Address(s):

09. Contact Phone(s) Number(s):

10. Contact Email Address(s):

11. Occupation:

12. Languages spoken: English French Other(s)

Insert or Attach Photo

(JPEG, BMP, PNG)

21)

CANDIDATES APPLICATION FORM

(For election or appointment to the FINA Bureau,

Committees and Panels 2017-20

13. Educational background/qualification**:

14. Athletic background (with focus on and understanding of aquatics)**: Yes (Please specify below) No

Please provide full details and relevant information**.

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Yes (Please specify below) No

* Please attach a copy of your passport ** Please use a separate paper sheet if necessary

IOC, FINA) or found to have been in breach of any FINA or other sport organizations rules? **

Yes (please provide full details and relevant information)** No

Yes (please provide full details and relevant information)** No

CANDIDATES APPLICATION FORM

(For election or appointment to the FINA Bureau,

Committees and Panels 2017-2021)

Yes (please provide full details and relevant information)** No

16. YesPosition in the FINA Continental Organization: (Please specify below) No

17. Position in the FINA Member Federation:

18. YesMember of other sport Organizations: (Please specify below) No

19. Have you ever been convicted by any Court of any criminal offence punishable by imprisonment?**

20. Have you ever been banned or suspended from participating in any sports related activity (eg. by WADA,

21. Have you ever hold any existing or prospective role that does or may place you in a situation of

conflict of interest with FINA? **

22. Have you ever been declared bankrupt or been disqualified from acting as director?

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I declare that I have read, fully understand and agree to comply with the FINA Code of Ethics (available

at http://www.fina.org/sites/default/files/fina_codeofethics.pdf). I also agree to comply and be bound by

all other FINA Rules and policies.

_______________________________________ ______________________________

Signature of the Candidate Date

Confirmation by the FINA affiliated Member Federation (and Continental Organizations for certain candidates for Bureau Members):

________________________________________ ______________________________

NB: THIS FORM SHALL BE RETURNED TO THE FINA OFFICE

BY EMAIL (sportsdep@fina.org) OR FAX (0041213126610)

FOR THE CANDIDATES TO THE FINA BUREAU NO LATER THAN 22 APRIL 2017 at 18:00 CET

FOR THE CANDIDATES TO THE FINA COMMITTEES AND PANELS NO LATER THAN 22 MAY 2017 at 18:00 CET

AFTER THESE DEADLINES APPLICATIONS WILL NOT BE ACCEPTED

Signature of the President/General Secretary/ Date and Official Stamp Executive Director of the Member Federation (and Continental Organization, if applicable).

CANDIDATES APPLICATION FORM

(For election or appointment to the FINA Bureau,

Committees and Panels 2017-2021)