Application for Election Workers 2010

(External Staff)
OFFICE USE ONLY
Election Day: Monday, October 25, 2010
HOME P.S.# Work Ward # WORK PS #
Submit your completed application in person to:
Office of the City Clerk, 2nd. Floor, 300 City Centre Dr., Mississauga ON.
LOCATION

Position Preference
POSITION
List 1, 2, 3, choices
DRO Operator Supervisor
Test: E S U
Mandatory Demonstrator Revising Officer

Part I
Last Name (please print) First Name Middle

Address (Street No. and Name) Unit City Postal Code

Telephone: Telephone:
(Home) (Business)

Are you willing to use your cell phone if required? Telephone:

(Cell)
YES NO
Have you been convicted of a criminal offence in Canada for which a pardon has not been granted? YES NO

Part II
Work History (Name and Address of current/most recent employer)

Current Job Position

Additional Qualifications (Please include all other skills & experience that relate to your application)

Part III
Are you related to a candidate running in the 2010 Mississauga Municipal Elections? (eg. spouse, friend, relative) YES NO

Are you willing to accept a position outside of your own ward? YES NO

Supervisor and Operator positions may involve lifting up to 30 pounds. Are there any physical or health
problems that would cause you to be unable to carry out these essential duties? YES NO
If yes, explain:

Do you have a valid driver’s licence and will you have a car at your disposal on Voting Day? YES NO

I declare that the information provided by me in this application for employment is, to the best of my knowledge, an accurate statement of the
facts. I understand that falsified statements on this application shall be considered sufficient cause for dismissal.

Signature of Applicant: Date:

The personal information on this form is collected under authority of the Municipal Act 2001, c.25 and the Municipal Elections Act 1996, c.32 and will be used for the hiring of election staff only.
Questions regarding the collection and use of this information should be directed to the Election Coordinator, Office of the City Clerk, 2nd Floor, 300 City Centre Drive, Mississauga, Ontario L5B 3C1.
Tel.:905-615-3200 ext. 4433.

WE THANK ALL APPLICANTS, HOWEVER ONLY THOSE SELECTED WILL BE CONTACTED.

EL07 (2010) External