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Council / Committee Member
Declaration of Interest Form
If this information is required in an alternate format, please contact the Accessibility
Coordinator at 905-623-3379 ext. 2131.
This form shall be completed by the Member for each matter for which the Member is
declaring an interest in accordance with the Municipal Conflict of Interest Act. The
completed form shall be provided to the Municipal Clerk, or designate, at the conclusion
of the meeting. Note, the details of the declaration shall be recorded in the Declaration
of Interest Registry and a copy of the completed form shall be posted on the Municipal
Website in addition to the Registry.
I, Councillor � V �_C'Q , declare a potential
(❑ deemed' / ❑ direct 110 indirect2) pecuniary interest on
Agenda
Details
❑ General Government Committee
❑Planning and Development Committee
E Council
Agenda Item /
Report number:
Date of meeting
for the following reason:
matter:_�c
Councillor Sign ture Date e-j-�C// - /
Date Rb-cp Vby the Clerk (or
Designate)
Notes: 'For a "deemed" direct or indirect pecuniary interest see Section 3 of the
Municipal Conflict of Interest Act.
2For an "indirect pecuniary interest' see Section 2 of the Municipal Conflict of
Interest Act.