Required fields are marked with asterisks (*)

Application for Citizen at Large Board Appointment

First Name

Last Name

Home Address

Town or City

Postal Code

Primary Phone Number

Secondary Phone Number

Email Address

Length of residency in Stony Plain or Parkland County

Please select the board(s) you are applying for in order of preference. Select N/A if you are not applying to the selected board.

Cultural Roundtable

Community and Social Development Roundtable

Planning Advisory Committee

Have you previously served on a Council Appointed Board or Committee?

Yes

No

List past volunteer experience.

Describe any specific knowledge or experience you have related to the board(s) you have selected.

Describe what your primary goals are for the board(s) you have selected.

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

Describe how your business, work or educational experience relates to the board(s) you have selected.

What skills will you bring to the board(s) you have selected?

Signature

Clear

The personal information requested on this form is being collected under the authority of Section 33(c) of the Freedom of Information and Protection of Privacy (FOIP) Act and will be used for the purpose of selecting board members for the Town of Stony Plain. The personal information provided will be protected in accordance with Part 2 of the Act. If you have any questions regarding the collection, use or disclosure of personal information, please contact the FOIP Coordinator at 780-963-2151.