Required fields are marked with asterisks (*)

Application for public member appointment

Community and Social Development Roundtable

Name

Mailing Address

Municipality

Postal Code

Primary Phone

Secondary Phone

Email Address

Do you live or work in Stony Plain?

Yes

Do you live in Parkland County?

Yes

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

Yes

Are you currently a public member of the Community and Social Development Roundtable and applying to sit for a subsequent term?

Yes

Please indicate why you are interested in being a public member of the Community and Social Development Roundtable.

What goals do you hope to achieve by being a member of the Community and Social Development Roundtable?

Please describe any specific knowledge or experience you have related to the Community and Social Development Roundtable.

Please indicate community involvement and/or other volunteer activities.

Signature

Clear

The personal information requested on this form is being collected under the authority of Section 4(c) of the Protection of Privacy (POPA) Act and will be used for the purpose of determining eligibility and qualifications for a position with a Town of Stony Plain board or committee. If you have any questions regarding the collection, use or disclosure of personal information, please contact the FOIP Coordinator at 780-963-2151.