You must have JavaScript enabled to use this form. Current About You Why You are Applying Signature Complete PLEASE NOTE: We are only accepting applications for the Southwest Middlesex Health Centre Board of Directors at this time. Contact Information First and Last Name Email Phone Address (include town and postal code) Which of the following apply to you? (Please select all that apply.) 18 years of age or older Resident, Tenant or Land Owner in Middlesex Centre In which committees are you interested? (Please select all that apply.) Community Services Advisory Committee Youth Advisory Committee Cemetery Committee Southwest Middlesex Medical Centre Board Middlesex Centre Regional Medical Clinic Board of Directors Community Schools Alliance Livestock Valuers If you selected more than one committee or board above, which is your preferred choice? Are you able to attend meetings and other events during business hours? Yes No Occasionally, with Advanced Notice Leave this field blank
