Name*

Address*

City

Province*

Postal Code

Number of Years in Camrose

Please Select Preferred Contact Method

Phone Res Phone Bus Cell Fax Number Email Address

Contact Method

Where did you hear about this opportunity?

Camrose Booster Camrose Canadian Camrose Morning News Water Bill

Word of Mouth City Website Chamber of Commerce Volunteer Centre

Application to serve on 1st Choice*

Assessment Review Board Camrose Affordable Housing Committee Camrose Airport Commission Camrose Green Action Committee Camrose / Japan Friendship Society Camrose Police Commission Camrose Public Library Board Social Planning Advisory Committee Subdivision and Development Appeal Board

Application to serve on 2nd Choice

Assessment Review Board Camrose Affordable Housing Committee Camrose Airport Commission Camrose Green Action Committee Camrose / Japan Friendship Society Camrose Police Commission Camrose Public Library Board Camrose Regional Solid Waste Authority Social Planning Advisory Committee Subdivision and Development Appeal Board

Occupation

Employer

Note: A personal resume outlining any additional information may be attached.

Community Involvement

Interests/Hobbies

Please indicate your interest in the above Board/Commission(s) and briefly state the qualifications and experiences that you have that would make you an asset to this Committee.

Other Comments

Personal Reference 1 - Name

Relationship to Applicant

Contact Info

Personal Reference 2 - Name

Relationship to Applicant

Contact Info

Would you be available to attend meetings?

in the evening

during the day

I agree to serve on the above boards/committee(s) if appointed. I have reviewed the board/committee descriptions and am able to regularly attend meetings as required.

Yes

Kindly tell us a bit about yourself in a format that will serve as a brief introduction (2 - 3 sentences). Your introduction will be shared with the Member at Large Review Panel, and if selected, in the report to City Council regarding your appointment. If appointed, this introduction will form part of the public record.

Prior to confirmation of appointment by Council, applicants will be required to provide a Criminal Records Check, which will be provided at no cost to the appointee.

The personal information that is being collected under Section 33 and is protected by the privacy provisions of the Freedom of Information and Protection of Privacy Act. If you have questions, contact the FOIP Coordinator at (780) 672-4426 ext. 1063.

Date of Application:

The information on this form is being collected under the authorization of Section 33(c) of the Freedom of Information and Protection of Privacy Act and, as such is protected by the provisions of this Act. If you have any questions, contact the FOIP Coordinator at (780) 678-3027.