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Expression of Interest Public Committees, Boards and Councils

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Expression of Interest Public Committees, Boards and Councils EXPRESSION OF INTEREST PUBLIC COMMITTEES, BOARDS AND COUNCILS You may submit your Expression of Interest in the following ways: • Complete the online form; or • Complete the application form below and either e-mail it or print and mail it to: Registrar, Board Appointments Department of Executive Government of the Northwest Territories Box 1320 Yellowknife NT X1A 2L9 Phone: (867) 767-9156 ext. 11101 Fax: (867) 873-0279 Email: [email protected] Expression of Interest will be retained on file for two years. Name: Full Mailing Address: Telephone: (Home) (Bus.) (Cell) Email: Fax: Please select which public board do you wish to be considered for? You may apply to as many Boards as you wish. Aboriginal Languages Revitalization Board Agricultural Products Marketing Council Apprenticeship, Trade and Occupation Certification Assessment Appeal Tribunal Board Aurora College Board of Governors Beaufort Delta Regional Wellness Council Beverly and Qamanirjuaq Caribou Management Dehcho Regional Wellness Council Board Dental Registration Committee Environmental Studies Management Board Fort Smith Regional Wellness Council Gwich’in Arbitration Panel Gwich’in Land and Water Board Gwich’in Land Use Planning Board Gwich’in Renewable Resources Board Hay River Regional Wellness Council International Porcupine Caribou Board Inuvialuit Arbitration Board Inuvialuit Environmental Impact Review Board Inuvialuit Environmental Impact Screening Committee Inuvialuit Water Board Judicial Appointments Advisory Committee Judicial Council for Territorial Judges Justices of the Peace Review Council Legal Aid Commission of the Northwest Territories Liquor Licensing Board Mackenzie River Basin Board Mackenzie Valley Environmental Impact Review Board Mackenzie Valley Land and Water Board Medical Registration Committee Mine Occupational Health and Safety Legislation Mining Industry Advisory Board Committee Natural Resources Conservation Trust Fund Board Northwest Territories Arts Council of Trustees Northwest Territories Business Development and Northwest Territories Egg Producers Board Investment Corporation Board Northwest Territories Health and Social Services Northwest Territories Judicial Remuneration Leadership Council Commission Northwest Territories Power Corporation Northwest Territories Review Board (Board of Directors) Northwest Territories Social Assistance Appeal NWT Surface Rights Board Board Official Languages Board Porcupine Caribou Management Board Public Utilities Board of the Northwest Territories Safety Advisory Committee Sahtu Arbitration Panel Sahtu Land and Water Board Sahtu Land Use Planning Board Sahtu Regional Wellness Council Sahtu Renewable Resources Board Status of Women Council of the Northwest Territories Student Financial Assistance Appeal Board Territorial Board of Revision Tlicho Community Services Agency Victims Assistance Committee Waste Reduction and Recovery Advisory Wek’eezhii Land and Water Board Committee Wek’eezhii Renewable Resources Board Wildlife Management Advisory Council (NWT) Workers’ Compensation Appeals Tribunal Workers’ Safety and Compensation Commission Governance Council Yellowknife Regional Wellness Council Are you a beneficiary or participant of an NWT Land Claim? If yes, are you a beneficiary or participant of? Acho Dene Kue First Nation Akaitcho Dene First Nation Dehcho First Nations Gwich’in Final Agreement Inuvialuit Final Agreement K’atl’odeeche First Nation NWT Métis Nation Sahtu Final Agreement Salt River First Nation Tłįchǫ Agreement Current place of employment and position: Employment Background: Education: Community/Committee Involvement: Previous Board Experience: Additional Information: Potential Conflict of Interest: Please provide details of any business or private, political interest or personal connections which might be relevant to the work of the Board concerned. These could include financial interests or share ownership, membership or societies, activities, associations or employment of a partner or friend in the particular field in which the public Board operates. Any potential conflicts of interest detailed here will not prevent your application being considered but may, if appropriate, be explored with you as part of the appointments process. Personal Information Acknowledgement: I understand additional personal information may be required from me if I am a candidate who is considered for appointment. Personal information about me may be collected from the Government of the Northwest Territories and used to evaluate suitability as a candidate, as well as, to verify the truth and accuracy of the information provided, and for no other purpose. Agree Disagree Privacy Act Statement This information is being collected under the authority of the Access to Information and Protection of Privacy Act (ATIPP) The privacy provisions of ATIPP protect this information. Personal information is defined under ATIPP. All applicants have the right to examine and request correction of his or her records and to request a review by the Information and Privacy Commissioner. If you have any questions about the collection of information, contact: Information and Privacy Commissioner 5018 – 47th Street PO Box 262 Yellowknife NT X1A 2N2 Phone (867) 669-0976 or toll free 1 (888) 521-7088 Submitted by: Date: .
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