Delegation Request Form - Thames Centre

Required fields are marked with asterisks (*)

Notice of Collection of Personal Information

Personal information on this form is collected under the legal authority of Municipal Act, 2001. The delegate’s information is collected and maintained for the purpose of creating a record that is available to the general public, pursuant to Section 27 of the Municipal Freedom of Information and Protection of Privacy Act. This information is collected and maintained for the purposes of preparing an agenda for Council. Questions or concerns about the collection of this information can be directed to the Clerk at 4305 Hamilton Road, Dorchester ON N0L 1G3, Phone: 519-268-7334 ext 254 or clerk@thamescentre.on.ca

Please complete this form if you wish to speak before Thames Centre Council.

Please note that submission of this form does not guarantee the approval of your request for delegation. All delegation requests are subject to the provisions outlined in the Procedure Bylaw. The Municipal Clerk will respond to your request by email after receiving this form.

Please note that the name and reason for delegation will appear on a public agenda of Council.

Name (First and Last)

Phone Number

Email Address

Municipal Address

Have you been in contact with municipal staff or council regarding this matter?

Yes

Do you have a preferred date to speak to Council?

Yes

Brief summary of issue or purpose of delegation.

Supplementary documentation (if applicable)

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Do you require any accessibility accommodations?

Yes

I understand that the Procedural by-law permits 10 minutes per delegation, including questions, and my presentation must be limited to that time.*

I agree