Date:

Petition subject matter:

(Briefly state the subject matter of your petition and the request for action within the authority of the Corporation of the County of Essex. If your petition is related to an upcoming agenda item, please indicate meeting date and report title.)

Total number of signatures:

Petition Organizer:

First and Last Name:

Mailing Address:

Email:

Telephone Number:

NOTE:

Petitions containing original signatures should be sent by mail to:

The Corporation of the County of Essex – Warden and Members of Council

Attention: County Clerk’s Office

Essex County Civic Centre, 360 Fairview Ave. W., Suite 201, N8M 1Y6

Alternately, Petitions may be delivered by hand in person to the address above, during regular business hours. For further information or inquiries, please contact the Clerk by email at clerks@countyofessex.ca. It is the responsibility of the Petition Organizer to confirm that the Clerk has received the Petition.

Statement: We, the undersigned, petition the Warden and Members of Essex County Council as follows:
(Briefly state the subject matter of your petition and the request for action within the authority of the Corporation of the County of Essex.)
First and Last Name	Civic Address Within the County of Essex (Primary Residence or Owned Property)	Original Signature
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