Take Survey

	Request to Speak to County Council (Delegation Request Form)

1.	Name of Delegates (Speakers)* List all the delegates (speakers) that will be attending and their position(s)/title(s).

2. Group/Organization/Business/Individual*
(Check appropriate box)

	Representing a Group/Organization/Business
	Attending as an Individual

3.	Reason(s) for Delegation Request:*

4.	Date of Council Meeting:* (County Council meets the 1st and 3rd Wednesday of each month at 7 PM except for the months of July and August where it only meets once).
	yyyy/mm/dd

5.	Recommendation to Council:* (Please indicate below what action you would like County Council to take with regard to your request.)

	Please provide contact information:

6.	Contact Name:*

7.	Contact Phone Number:* Please use the following format for phone number: XXX-XXX-XXXX

8.	Mailing Address:* Please include full mailing address including postal code.

9.	Email Address:*

Notice of Collection: Personal information collected on this form is authorized under the County of Essex Procedure By-law and will be used to contact individuals and/or organizations requesting an opportunity to appear as a delegation before Council. The name and address of the delegates or organizations will be published as part of the meeting agenda which is also posted on the County Website. Questions about this collection can be directed to the Director of Council Services/Clerk at (phone) 519-776-6441, ext. 1335 or email Mary Brennan.

	Additional Documentation and Presentation Materials

10. Additional documentation (information) attached?*

	Yes
	No

12.	Will a PowerPoint or any form of audio/visual presentation be made?* Note: An electronic copy of any PowerPoint or audio/visual presentation is required to be submitted to the Clerk no later than noon on the day of the meeting.
	YesNo

13.	Addtional documentation (information) to be provided at meeting?* Note: Please provide the Clerk with 25 copies of any printed information to be distributed at the meeting.
	YesNo