Board of Governors information form 123 To facilitate your involvement with the Board and participation in Board-related activities, please complete the form below in entirety.SECTION 1: PERSONAL INFORMATION OF GOVERNORName* First Last Preferred Name (e.g. Debbie for Deborah)Address* Street Address Address Line 2 (e.g., apartment, suite, PO Box) City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Date of Birth (yyyy-mm-dd)* YYYY slash MM slash DD Phone*Email* *the telephone number and email you provide in this section will be how Durham College will communicate with you regarding Board and College businessFood allergies/dietary restrictions Name Used on Legal Travel Documents* First Last Clothing Size (e.g., jackets, golf shirts)OptionalDo you identify as a: Woman Visible Minority/Racialized Person Person with Disability Indigenous *The data collected in this section will be used to inform the Board’s skills matrix. This data may be shared with other members of the Board or officers of the Board for administrative purposes. However, this information will only be shared publicly in aggregate format.SECTION 2: PERSONAL INFORMATION OF SPOUSE/PARTNERName First Last PhoneDate of Birth (yyyy-mm-dd) YYYY dash MM dash DD Food allergies/dietary restrictions Name Used on Legal Travel Documents First Last SECTION 3: EMPLOYMENT INFORMATIONOrganization NamePosition TitleAddress Street Address Address Line 2 (e.g., apartment, suite, PO Box) City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Name of Assistant First Last Telephone Number of AssistantEmail of Assistant Would you like your assistant to be copied on all email communications? Yes No SECTION 4: VEHICLE INFORMATIONVehicle 1MakeModelModelColourColourLicense PlateLicense PlateVehicle 2MakeModelModelColourColourLicense PlateLicense Plate*As a Governor, you are entitled to receive a complimentary parking pass for use at all Durham College facilities for the term of your serviceSECTION 5: CONSENTConsent to Hold Office As an individual elected or appointed to the Board, I hereby acknowledge and declare that I: consent to act as a governor of the Corporation; am at least 18 years old; have not been found under the Substitute Decisions Act, 1992 or under the Mental Health Act to be incapable of managing property; have not been found to be incapable by any court in Canada or elsewhere; do not have the status of an undischarged bankrupt; have not been convicted of a criminal offense; am not an employee of any college of applied arts and technology (*applies to external governors only). Hold office declare* Yes, I declare No, I don’t declare If no, please explain*Meeting Participation I consent to the holding of Board and Board committee meetings, whether partially or entirely, by telephonic or electronic means that permit all persons participating in the meeting to communicate adequately with each other during the meeting. I also consent to the participation by any governor or Board committee member at a Board or Board committee meeting by such telephonic or electronic means.Meeting declare* Yes, I declare No, I don’t declare If no, please explain*Email communication I consent to accepting information or documents by electronic means at the email address noted below, such consent to continue in effect unless revoked by an instrument in writing delivered to the Corporation.Email declare* Yes, I consent No, I don’t consent If no, please explain*Photography Do you consent to having your photograph taken and used for college-related purposes?Photo declare* Yes, I consent No, I don’t consent If no, please explain*Canada’s Anti-Spam Legislation Durham College values the opportunity to provide you with information on our programs, events, unique business and partnership opportunities, services and more. Under the Canadian Anti-Spam Legislation, we require your consent to contact you via email with this information.CASL declare* Yes, I consent No, I don’t consent If no, please explain*Compliance with Legislation, By-laws, Policies and Codes I confirm that I have read and understand, or will promptly read and understand, all of the policies and codes of conduct of the College applicable to me including the following policies and codes of conduct which have been approved by the board (collectively the “Policies and Codes”). By-law 1 Mission, Vision, Values and Strategic Goals Governor’s Duties and Responsibilities Governor Code of Conduct Roles and Duties of Officers Recruitment and Reappointment of External Governors Committee Terms of Reference Consent Agenda I agree to act with honesty and integrity in the best interests of the College and to comply with the Policies and Codes, the by-laws of the College and such other Policies and Codes that are applicable to the board, including: Minister’s Binding Policy Directive: Conflict of Interest. I agree to comply with the Not-for-Profit Corporations Act, 2010 (the “Act”) and the Corporation’s by-laws, and Policies and Codes.Policy declare* Yes, I consent No, I don’t consent If no, please explain*Conflicts In accordance with the by-laws of the College, I make the following declaration: I have an interest, directly or indirectly, in the following entities which include any body corporate, partnership, not-for-profit organization, charity, association, committee or other business or charitable enterprise in which I am a director or officer (but which does not include businesses in which I own less than 2% of the issued and outstanding shares):Conflict declarationSECTION 6: BIOGRAPHYPlease provide your biography for use on the College website and Board portal (approximately 200 words) CONFIDENTIALITY AGREEMENT Protocol regarding Confidentiality 1. Regular Board meetings are open to the public and/or media. Once the Board has dealt with an issue in a regular meeting, the issue is considered to be in the public domain; 2. The Board also holds in-camera meetings, where items are discussed relating to legal, personnel, acquisition of property, or other matters deemed to be confidential and provided for under the Freedom of Information and Protection of Privacy Act (FIPPA). Such topics are confidential until they are discussed at the regular (public) Board meeting; 3. Standing Committees are advisory to the Board. Only the full Board makes formal decisions. Standing Committee meetings are held in-camera, with the exception of the Governance Review Committee meetings, and such discussion and recommendations shall not be discussed publicly. Undertaking respecting Confidentiality During the time that I serve on the Board of Governors I will gain access to information that is confidential and/or proprietary. Since confidential and proprietary information is crucial to the operation of the Board, and shall be protected, I agree that I will not use, publish or disclose such information during my participation on the Board of Governors and that I will preserve the restricted nature of this information except to the extent that it becomes publicly available. Additionally, as a member of the Board of Governors I have an obligation to disclose any potential or actual conflict of interest. This agreement shall not apply to governors who also sit on the UOIT Board as “Co-populous” governors in instances where these co-populous governors have confidential information that is interrelated to both institutions. I hereby certify that I have read, understand and agree to be bound by the Board’s policies as described in this statement, with respect to confidential information and conflict of interest and that the information given in this statement is complete and accurate to the best of my knowledge. I further understand that this agreement remains in force, even if I cease to have an association with Durham College. Dated* YYYY slash MM slash DD Consent* I agree to the confidentiality agreement. PERSONAL SKILLS ASSESSMENT The board seeks a complementary balance of knowledge, skills, and experience. Please indicate your areas and depth of knowledge, skills, and experience by checking the relevant boxes in the table below. It is not expected that you possess knowledge, skill or experience in all the areas set out in the table. SkillLevel of ExpertiseDetails Advancement/FundraisingAdvancement/Fundraising* Basic Intermediate Advanced No experience Please describe your experience AdvocacyAdvocacy* Basic Intermediate Advanced No experience Please describe your experience Change ManagementChange Management* Basic Intermediate Advanced No experience Please describe your experience Capital PlanningCapital Planning* Basic Intermediate Advanced No experience Please describe your experience Data AnalyticsData Analytics* Basic Intermediate Advanced No experience Please describe your experience Digital LiteracyDigital Literacy* Basic Intermediate Advanced No experience Please describe your experience Diversity & InclusionDiversity & Inclusion* Basic Intermediate Advanced No experience Please describe your experience Finance/Investment/AccountingFinance/Investment/Accounting* Basic Intermediate Advanced No experience Please describe your experience Governance (previous to DC, greatest emphasis)Governance (previous to DC, greatest emphasis)* Basic Intermediate Advanced No experience Please describe your experience Government/Political KnowledgeGovernment/Political Knowledge* Basic Intermediate Advanced No experience Please describe your experience Human Resources/Labour RelationsHuman Resources/Labour Relations* Basic Intermediate Advanced No experience Please describe your experience Indigenous/Aboriginal HistoryIndigenous/Aboriginal History/Community* Basic Intermediate Advanced No experience Please describe your experience Policy DevelopmentPolicy Development* Basic Intermediate Advanced No experience Please describe your experience Public Relations/Stakeholder RelationsPublic Relations/Stakeholder Relations* Basic Intermediate Advanced No experience Please describe your experience Regulatory/LegalRegulatory/Legal* Basic Intermediate Advanced No experience Please describe your experience Risk ManagementRisk Management* Basic Intermediate Advanced No experience Please describe your experience Strategic PlanningStrategic Planning* Basic Intermediate Advanced No experience Please describe your experienceCOMMUNITY INVOLVEMENT (NOT TO DUPLICATE OCCUPATION ABOVE) Arts/Entertainment/Recreation Business and Industry Community Services Education and Training Government/Political Health Services Non-Profit Service Clubs Other CAPTCHAEmailThis field is for validation purposes and should be left unchanged. Notice of collection: In accordance with Section 39(2) of the Freedom of Information and Protection of Privacy Act, 1990, the personal information collected on this form is collected under the legal authority of the Ontario Colleges of Applied Arts and Technology Act, 2002 and may be used and/or disclosed to facilitate your involvement with the Durham College Board of Governors during the term of your service and to keep in contact with you once your service has ended. If you have any questions about the collection, use and disclosure of your personal information by the College, please contact the Freedom of Information and Protection of Privacy Coordinator, 2000 Simcoe Street North, Oshawa, ON, L1G 0C5, 905.721.2000 ext. 3292.
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