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APPLICATION FOR APPOINTMENT TO <br />ESSEX COUNTY ACCESSIBILITY ADVISORY COMMITTEE <br />Please complete the following application by 4:30 p.m., December 3 2010 and <br />submit to: <br />Mary Brennan <br />County of Essex <br />Suite 202 <br />360 Fairview Avenue West <br />Essex, Ontario <br />N8M 1Y6 <br />ELIGIBILITY CRITERIA (please check the boxes applicable to you) <br />PERSONAL DATA ❑ Mr. ❑ Mrs. ❑ Ms. <br />MAILING ADDRESS AND CONTACT INFORMATION <br />Name <br />Address <br />Postal Code <br />Telephone: (519) 776 -6441 Ext. 335 <br />Fax: (519) 776 -4455 <br />E -mail: mbrennan@countyofessex.on.ca <br />Website: www.countyofessex.on.ca <br />I am a resident or owner /tenant of land in Essex County <br />I am a Canadian Citizen <br />I am at least 18 years old <br />I am not an employee of the Corporation of the County of Essex <br />I am not prohibited by law from voting in a municipal election <br />I am a person with a disability <br />I am a professional from the disability stakeholder community <br />Telephone # (Home) (Business) <br />Fax E -mail Address <br />EXPLAIN WHY YOU WOULD LIKE TO SERVE ON THE ESSEX COUNTY <br />ACCESSIBILITY ADVISORY COMMITTEE (attach a separate sheet if necessary) <br />