Application for Appointment to Municipal Elections Compliance Audit Committee

Submit only one application per person; attach resume, if applicable. Please Print or Type

Application Deadline is Friday, July 20, 2018

Personal Information: � Mr. � Mrs. � Ms. (Please choose one)

Name:

Home Address: Street City Postal Code

Mailing Address: (If different than above) Street City Postal Code

Telephone: Home Business

E-Mail: ________________________________________________

List all advisory committees or special purpose bodies that you are presently serving on or were previously appointed to by any municipality.

From (date) To (date)

1. to

2. to

3. to

Relevant Educational Background:

Relevant Occupational Background:

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What qualifications can you bring to the Municipal Elections Compliance Audit Committee? Please include any other reasons for applying or information that you think would be helpful in making a decision.

Are you available to attend meetings: During business hours? Yes No In the evening hours? Yes No

Does travel within the Region of Waterloo and the City of Guelph pose a problem? During business hours? Yes No In the evening hours? Yes No I agree that, if appointed, I will abide by all applicable policies established relating to the Conflict of Interest policy. I am a property owner or resident of the Region of Waterloo or the City of Guelph being 18 years of age or older. Signature Date Return to: Office of the Regional Clerk Regional Municipality of Waterloo 2nd Floor, 150 Frederick Street Kitchener ON N2G 4J3 Phone 519-575-4400 or Fax 519-575-4481 Email: regionalclerk@regionofwaterloo.ca Personal information is collected under the authority of the Municipal Elections Act and will be used to determine suitability for appointment. Questions regarding the collection of personal information should be directed to the above noted, Office of the Regional Clerk. Applicants are responsible to ensure that their application has been received by the Regional Clerk. For Office Use Only: Application copied to Regional Clerk Date: Appointment approved by Area Clerks Date: Notification letter sent Date:

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