Norfolk County > Norfolk County Council Committees Application Form

Norfolk County Council Committees Application Form

Surname:(Required)

Given Name(s):(Required)

Address:(Required)

Street Address City Postal Code

Home Telephone:

Business Telephone:

Cell:

Fax:

Email:(Required)

Committees contribute to Council’s decision making processes and help shape municipal policy. As such, it is important for potential committee members to understand the terms of reference for the committees to which they are applying and to be available to fulfill the commitment required. The Committee’s By-Law outlining the terms of reference for each committee can be found through the Clerk’s Division, 50 Colborne Street South, Simcoe, Ontario, N3Y 4H3.

Committee Preference*

1st Choice:(Required)

2nd Choice:(Required)

*If you are applying for the Accessibility Advisory Committee, please note that the Accessibility for Ontarians with Disabilities Act, 2005 requires that a majority of the committee members be persons with disabilities.

Do you have a disability?(Required)

Yes

Prefer not to identify

Background Information

Describe your interest in the committee(s) identified above and your order of preference:

Describe any specific knowledge or experience you have related to the committee(s) in which you have expressed interest:

If appointed, are there any issues that you feel should be considered by the committee(s) you have selected?(Required)

Yes

Please describe:

Describe any prior experience you have serving on a committee or board:

What was your most significant learning experience?

What was your most significant contribution?

How would you describe the way in which you work with others?

General Information

Place of Employment:(Required)

Nature of Employment:(Required)

Length of Residence in Norfolk County:(Required)

Community Interests and Activities:

Skills

Volunteer Management

Fundraising Experience

Arts Education

Program Development

Finance

Marketing and Promotion

Other (please describe):

References

Please list three individuals who can provide a personal reference (please list telephone numbers and/or email addresses for each individual):

Reference #1 - Name:(Required)

Relationship to Applicant:(Required)

Contact Information(Required)

Reference #2 - Name:(Required)

Relationship to Applicant:(Required)

Contact Information:(Required)

Reference #3 - Name:(Required)

Relationship to Applicant:(Required)

Contact Information:(Required)

Applicants shall represent all geographic and community areas of Norfolk county i.e. East/West, urban/rural. All successful Appointees must be willing to undergo a Criminal Reference Check to be paid for by Norfolk County.

I agree to serve on the above committee(s) if appointed. I have reviewed the Committee descriptions and I am able to regularly attend meetings.

Signature:(Required)

Date:(Required)

The personal information on this form is collected under the authority of the Municipal Act, 2001, S.O. 2001, Chapter 25, as amended, and is used solely for the purposes related to the appointment of citizens at large to Council committees. If you are appointed to a Council committee your name may be viewed by the public. If you have any questions about the use of this information contact the County Clerk 50 Colborne St. S. Simcoe, ON N3Y 4H3

Teresa Olsen, County Clerk

Norfolk County Administration - Clerks & By-law Department

50 Colborne Street South

Simcoe, ON, N3Y 4H3

Phone: 519-426-5870, Ext. 1228

E-mail: [email protected]