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CONSENT TO RELEASE PERSONAL INFORMATION
Municipal Freedom of Information and Protection of Privacy Act
Personal information on a Nomination or Registration form is collected under the authority of the Municipal
Elections Act, 1996 and will be used to assist the City Clerk in the administration of the 2018 Municipal
Election.
Questions regarding this collection should be forwarded to ElectionCampaigning@kitchener.ca.
Indicate if you are a candidate or a third party advertiser:
Third Party Advertiser
Candidate for the office of:
Mayor
Councillor, Ward # _______
Waterloo Region District School Board
Waterloo Catholic District School Board
Conseil scolaire catholique MonAvenir
Name of Candidate or Third Party Advertiser: ________________________________________________
In addition to the information provided on the Nomination/Registration form, you are permitted to submit one
URL to be displayed on the City of Kitchener candidate and third party advertiser webpage.
URL: ____________________________________________________________________
You may also email ElectionCampaigning@kitchener.ca with your URL
If you would like any information omitted from the City of Kitchener candidate and third party advertiser
webpage, acknowledging the Nomination or Registration form filed by you is available for public inspection at
City Hall, please indicate it below.
_________________________________________________________________________
Requested information to be omitted online
The City will not check for any changes to the information provided as it is the responsibility of the candidate or
third party advertiser to advise the City of any changes.
I acknowledge the personal information contained within the Nomination Paper (Form 1) or Notice of
Registration - Third Party ( Form 7) filed by me will be disclosed to the general public.
Signature of Candidate/Third Party Advertiser
X
OFFICE USE ONLY:
Dated at the City of Kitchener
(municipality)
of Region of Waterloo
(county, district or regional municipality)
This ___________ day of _______________ . 20 ________.
day month year
________________________________________________________
Signature of City Clerk or Designate