Source Water Protection Committee Application Form

Name:

Civic Address:

Address Line 1

Address Line 2

City

Province

Postal Code

Mailing Address:

Address Line 1

Address Line 2

City

Province

Postal Code

Phone number:

Email address:

Please select the community whose committee you are applying for:

Do you own land within the Source Water Protection Area?

Yes
No

If yes or unsure, list the PID or civic address of any properties within the community:

Are you a customer of the municipal water system?

Yes
No

If yes, list your water utility account number or civic address:

Qualifications

Please describe any personal or professional experience or any other qualifications you have that you feel would benefit the Source Water Protection Committee for your community.

Are you aware of any potential conflicts of interest as a Source Water Protection Committee member?

I am over 18 years of age.
I do not have any real or perceived conflict of interest with the committee, including direct or indirect pecuniary interest with the municipality, staff, and/or individual councillors.

any the the

Date Submitted: