World Bank Group S Civil Society Consultative Group

Nomination Form for Membership

World Bank Group’s Civil Society Consultative Group

on Health, Nutrition and Population (WBG-CSCG-HNP)

January 2015

This is a Call for Nomination to select 7 new members of the World Bank Group’s Civil Society Consultative Group on Health Nutrition and Population, bringing the group’s total to 16. Currently 9 members will be serving an additional 18 months term. Established in 2011, this group aims to provide a structured and transparent mechanism for CSOs to contribute to; influence; and share information, lessons learned, and advice on the development and impact of Bank plans and policies and programs in HNP in low- and middle-income countries, in the context of the WBG’s goals to end poverty and boost prosperity and the HNP Global Practice goal to end preventable deaths and disability by 2030. See attached Terms of References for more information about the group.

Interested persons should complete this nomination form and send an email to [email protected] with a copy of your CV and a signed letter of nomination from your supervisor or senior executive of your organization no later than 5 pm (1700 hours), Eastern Standard Time (EST), Friday January 30, 2015.

Support of Nomination Do you have the consent of your organization to serve as a member of the World Bank Group’s Civil Society Consultative Group on Health, Nutrition and Population?

☐Yes ☐No

If yes, please attach a letter of nomination from your supervisor or a senior executive of your organization.

Nominee Information ☐Mr. ☐Mrs. ☐Ms. ☐Dr. ☐Professor

Last Name: First Name:

Page | 1 Title: Organization: Telephone (including country code) Email: Country where you are based: Nationality:

I have regular access to the following communications channels (please check all that apply):

☐Email ☐Broadband Internet ☐Teleconferencing ☐Videoconferencing

Nomination Questions

1. Briefly describe your work on Health, Nutrition and Population at the global, regional and country levels, and what you would contribute to the work of the Group, listing the countries you have worked in and the number of years of experience in each (please limit your response to no more than 2 paragraphs):

2. Please check the following areas of expertise in Health, Nutrition and Population that apply to your experience (please check all that apply):

☐Gender ☐Non-Communicable disease ☐Health Financing ☐Nutrition ☐Health Service Delivery ☐Pandemics ☐Health Systems ☐Population, reproductive and sexual health ☐Health Workforce ☐TB ☐HIV/AIDS ☐Universal Health Coverage ☐Malaria ☐Vaccines ☐Maternal, neo-natal, and child health ☐Other (please specify)

3. Briefly describe your interest and objectives for seeking membership in the World Bank Group’s Civil Society Consultative Group on Health, Nutrition and Population (please limit your response to no more than 2 paragraphs):

4. Briefly describe relevant global, regional and national civil society networks in which you or your organization actively participate in and how you would facilitate communication with and solicit views from other health and development CSOs (please limit your response to no more than 2 paragraphs):

Nominee References Please list the names and email contact of 2 professional references, from outside your organization, that we may contact regarding this nomination:

Page | 2 1. Name: Email: 2. Name: Email:

Thank you for your interest in joining the World Bank Group’s Civil Society Consultative Group on Health Nutrition and Population. . For questions, please send an email to [email protected]

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