Clarington Municipal Election Compliance Audit Committee Application

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1 Instructions Completed applications can be hand-delivered or sent by regular mail, fax or and must be received by noon on Friday, April 20, Hand-deliver or mail to the Municipal Clerk s Office, Municipal Administrative Centre, 2 nd Floor, 40 Temperance Street, Bowmanville, ON L1C 3A6 Fax to: Fax alert: Sending personal information by fax is not a secure means of transmission. It is recommended that you complete and return the application form by regular mail. to: clerks@clarington.net Any personal information provided on this form will be subject to public inspection as per the terms of section 88(5) of the Municipal Elections Act, Applicant Last Name First Name Mailing Address Unit No. City Postal Code Address (update when available) Business Phone No. Home Phone No. Questionnaire & Certification Note: Applicants may attach additional sheets, if necessary, to respond to these questions. The committee shall be composed of three members and shall not include: employees or officers of the Municipality of Clarington; members of Clarington Council; or any candidates in the 2018 municipal election and any by-elections during Council s term. Are you any of the aforementioned? Yes No What is your occupation? Outline your knowledge of the campaign financing rules in the Municipal Elections Act, Page 1 of 6

2 What are your qualifications and experience for this position? Page 2 of 6

3 If you are currently serving, or have previously served, in an elected or appointed capacity on an agency, board or commission, ratepayer group or similar organization, please give details. (Please include the name of the board or group and your years of service.) Page 3 of 6

4 Explain how your appointment will benefit the committee Page 4 of 6

5 How much time would you be willing to commit to the business of the committee, including attendance at meetings? (Please indicate availability during business hours as well as in the evening.) Resume or other information attached? Yes No Would you have any conflicts of interest or potential conflicts of interest if you were appointed? Yes No Page 5 of 6

6 If yes, please describe the general nature of the conflict of interest (e.g. providing financial assistance or legal counsel to any candidate running for council in the 2018 municipal election). Note: Any person appointed to the Clarington Election Compliance Audit Committee must agree in writing to not provide advice to, prepare or audit the election financial statements of any candidate for office on Clarington Council or become a candidate in the 2018 municipal election and any byelections during Council's term. I hereby certify that the information contained in this application form is accurate. Signature Date The term of office for the Clarington Election Compliance Audit Committee is from December 1, 2018 to November 30, 2022 to deal with applications from the 2018 election and any by-elections during Council's term. I consent to share my contact information with other municipalities or school boards for possible appointment to their Compliance Audit Committee. Yes No The personal information on this form is collected under the authority of the Municipal Elections Act, 1996, s and the Municipal Act. The information is used to assess an applicant s eligibility to serve on the Clarington 2014 Election Compliance Audit Committee. Pursuant to s. 88 of the Municipal Elections Act, 1996, this document is a public record, despite anything in the Municipal Freedom of Information and Protection of Privacy Act (1990), and, until its destruction, may be inspected by any person at the Municipal Clerk s Office at a time when the office is open. Questions about this collection can be directed to: Municipal Clerk, 40 Temperance Street, Bowmanville, ON L1C 3A6 or by telephone to ext Page 6 of 6