Required fields are marked with asterisks (*)

Requesting a Delegation to Council or Committee

Name

Street Address

City/Town/Village

Province

Postal Code

Telephone

There can be a maximum of two speakers for each deputation. Please list the name(s) of the individual(s) who will be speaking. The names that are listed here will be included on the Council Meeting Agenda.

Deputant One

Deputant Two

Please provide details of the matter to which you wish to speak

Please upload any additional supporting documents you wish to provide

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

Have you discussed this matter with County staff?

Yes

What action are you hoping will result from your presentation/deputation?

By signing this form you are acknowledging that all of the information you are providing on this form is true, and giving the City permission to collect your personal information for the principal purpose of a request to make a deputation to Committee or Council as outlined below.

Signature

Clear

Date

The personal information is being collected by the County of Haliburton for the principal purpose of a request to make a deputation to Committee or Council pursuant to the County's procedural by-law. This information, including all attachments submitted may be circulated to members of Council, staff, the general public and posted on the County website. Questions about the collection of this information should be directed to the County Clerk at 705 286-1333 ext. 223.

Do you understand how your information will be used and agree to allow the County to use your personal information provided on this form, including any attachments for the purposes of requesting to make a deputation to Committee or Council?

Yes

Please complete this form and return to the County Clerk's Office by submitting it online or emailing to CAOclerk-info@haliburtoncounty.ca