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Committee Lay Member Application Form

Name

Title

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Been cited with or disciplined, censured, suspended or disqualified by any professional association or body?

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Had any improper dealings with government (e.g. improper solicitation of contracts, improper lobbying or representations)?

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Been involved in any issue or controversy that has gone, or is likely to go, to litigation or public review?

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Made an assignment or lodged a proposal under the Bankruptcy and Insolvency Act?

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Been discharged, suspended or asked to resign from any employment?

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If yes, please describe

Are you aware of any circumstances that may place you in a real, perceived, or potential conflict of interest with respect to your duties as a committee member?

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If yes, please describe

Have you or any organization or group that you are associated with promoted or encouraged hatred against people or persons on the basis of ethnicity, language, colour, religion, culture, gender or sexual orientation?

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Generally, are you aware of any facts or matters which, if publicly disclosed, could cause Engineers and Geoscientists BC embarrassment or hinder your performance of your duties as a committee member

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Disclose any issues that may be of public interest in the event you are elected to serve

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Confidentiality Acknowledgement

Engineers and Geoscientists BC collects, uses and retains the information on this form in accordance with the Freedom of Information and Protection of Privacy Act (RSBC 1996 Ch.165). The information is used for the purpose of evaluating candidates for an Engineers and Geoscientists BC position

Authorization Acknowledgement

Successful criminal record checks, confirmation of education credentials and professional references may be a required component of our volunteer selection process

Conflict of Interest Acknowledgement

I understand I must promptly inform Engineers and Geoscientists BC if there are significant changes to any of the above responses

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Engineers and Geoscientists BC respectfully acknowledge that our office is located on the unceded ancestral territories of the xʷməθkʷəy̓əm (Musqueam), Sḵwx̱wú7mesh Úxwumixw (Squamish), and səlilwətaɬ (Tsleil-Waututh) Nations. As a provincial regulator, we are grateful to serve across a diverse province of over 200 Indigenous communities.

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