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7 <br />KiTcHENER <br />DECLARATION OF INTEREST <br />Municipal Conflict of Interest Act <br />Mayor/Councillor/Committee Member Name <br />Date of Meeting: <br />Item Title: <br />Report Number (if applicable): I <br />, ) G, 0. <br />(*Please circle the appropriate variable) <br />7CD(F rJa <br />c �-),, d <br />I, Mayor /k Councillor / Committee* member T <br />declare tha#Tbfalieve that I have a direct / indirect* pecuniary inter-6st as <br />defined in the Municipal Conflict of Interest Act related to the above <br />topic/item found on the Council/Committee agenda for the following <br />reason: <br />Mayor/Councillor/Committee Member Siggature: - <br />Date of Declaration:C <br />Date received: Crfi . aa, ao ict . <br />Date entered into registry:._ <br />FOR OFFICE USE <br />Received by: fV,-ZL)�--- <br />Registry updated by: <br />