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SENATE OF CANADA APPLICATION FORM
(Winter 2016 Senator Selection Process)
Note:
This form relates only to the transitional process for appointments to the Senate of Canada for Senator
positions representing Quebec, Ontario and Manitoba to be filled during Winter 2016. It must be
completed by individuals nominated by an organization.
Application packages must be submitted to [email protected]
no later than 12:00 p.m. Eastern Standard Time on February 15, 2016. Late or incomplete
application packages that do not meet the requirements set out in this form will not be considered.
PART I – MANDATORY INFORMATION
A. BIOGRAPHICAL INFORMATION
Full given names (no initials; underline name normally used)
Surname
Preferred language
of communication
English
French
Full home address
City
Number, street, apartment
Phone numbers
Gender
Province
Postal Code
Email address
Mobile:
Home:
Work:
B.
REQUIREMENTS
Note: Nominees must submit proof of their responses to section B by providing copies of government-issued photo identification (e.g., passport,
birth certificate, driver’s license) or institutional documentation (e.g., deed, lease agreement, bank statement), as appropriate, to prove the
requirements listed in this section. If selected, notarized copies of these documents will be required.
Definitions: In this section, the following definitions apply:
“residence” means the place where a person is ordinarily present and has made his or her home for a minimum period of two years
immediately prior to the application. An exception may be made in a case where a nominee is absent from the province of vacancy for
reasons of employment or education but can provide satisfactory proof he or she intends to return to his or her permanent residence in
the province of vacancy.
“net value” means the difference between the value of the real property and any liabilities on that real property (e.g., mortgage, liens)
“net worth” means the difference between the nominee’s total assets (including real property and personal property) and their total debts
and liabilities.
Date of Birth
(yyyy-mm-dd)
January 2016
Citizenship
I am a Canadian citizen
Real Property
I hold real property of a net value of $4,000
or more in the province of vacancy.
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Net worth (real and personal
property)
I have a net worth of at least $4,000.
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Residence
I am a resident, as defined above,
of:
Senatorial Division (only if from Quebec; check all that apply)
I hold real property of a net value of $4,000 or more in, or am a resident, as defined above, of, the following
Senatorial Division(s):
Ontario
De la Vallière
Grandville
Rougemont
Manitoba
De Salaberry
Gulf
Stadacona
I don’t know
Quebec
During the Winter 2016 Senator selection process, only vacancies in these Senatorial Divisions in Quebec as
established in the Constitution will be filled. For further certainty, you may consult the map
C.
POLITICAL ACTIVITIES/POLITICAL DONATIONS/LOBBYING ACTIVITIES
Note: Political activities, political donations and lobbying activities are not a bar to appointment.
Please indicate the following with respect to the last five (5) years. Attach a separate sheet if necessary.
Definitions: In this section, the following definitions apply:
“political activities” include, but are not limited to: being a member of a political party at any level of government in Canada; seeking
nomination to run as a candidate or being a candidate in an election of any level of government in Canada; fundraising for political
purposes; personally displaying campaign material; attending partisan events or social events sponsored by one particular political party, a
Minister, a Member of Parliament or Senator where such events are exclusively or primarily of a political or partisan character; and
managing a political campaign or campaigning personally on behalf of a candidate in an election. Political activities do not include
attending all-party candidates meetings in order to inform one’s right to vote, or voting in an election.
I have no political activities to disclose.
I have political activities to disclose. Please specify:
Political Donations
Have you made donations to a candidate for
political office, a political party or leadership
campaigns at any level of government in Canada?
Yes
No
Political Financial Arrangements
Have you made loans or credit arrangements, directly or indirectly, with a candidate for
political office, a political party or leadership campaigns at any level of government in
Canada?
No
Yes
If yes, describe the nature of these financial arrangements:
Lobbying Activities
Are you a registered lobbyist at any level of government in Canada?
No
Yes
If yes, describe the nature of your activities, including the level of government lobbied, the organization on whose behalf you are engaged to lobby,
and your position within the organization:
D.
CRIMINAL CONVICTIONS
Have you ever been convicted of a
criminal offence for which you have
not been granted a pardon?
Yes
No
January 2016
If yes, please provide details (e.g., charge(s), name of police force and city, province/state, country and date
of conviction):
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E.
PERSONAL QUALITIES
I have attached a curriculum vitae (CV) or biography outlining my employment history, major achievements and highlighting my relevant
skills and experience. The CV or biography should indicate any professional affiliations or titles and awards you have received for at least
the last ten years. The CV or biography must be a maximum of 3 pages long, and no attachments or other supplementary documentation are
to be submitted.
AND
I have attached a short (1 page maximum) personal statement outlining for the Advisory Board how I meet each of the following criteria:
1. the ability to bring a perspective and contribution to the work of the Senate that is independent and non-partisan;
2. a solid knowledge of the legislative process and Canada’s Constitution, including the role of the Senate as an independent and
complementary body of sober, second thought, regional representation and minority representation;
3. outstanding personal qualities, including adhering to the principles and standards of public life, ethics, and integrity;
4. the ability to make an effective and significant contribution to the work of the Senate, not only in my chosen profession or area of
expertise, but the wide range of other issues that come before the Senate.
5. a) a high level of experience, developed over many years, in the legislative process and public service at the federal or
provincial/territorial level; and/or
b) a lengthy and recognized record of service to my community, which could include my Indigenous, ethnic or linguistic community;
and/or
c) recognized leadership and an outstanding record of achievement in my profession or chosen field of expertise.
F.
INVITATION TO APPLY
I have been nominated to apply for an appointment to the Senate of Canada.
Specify the organization that has nominated you to apply
G. REFERENCES
I have attached three (3) letters of reference from individuals verifying the information found in this application and my suitability for
Senate appointment
H. BACKGROUND CHECK
I have attached a completed and signed Background Check Consent Form.
I.
DECLARATIONS
1)
I consent to the collection, use and disclosure of my personal information by the Advisory Board, the Prime Minister’s Office (PMO), the
Privy Council Office (PCO), other federal government institutions and third party entities contracted or contacted to support the work of
the Advisory Board for the purposes of this appointment process. I understand that the information provided will be held in confidence
and used in the appointment process in accordance with the law, including the Privacy Act.
2)
I acknowledge the ongoing obligation that, if appointed, I must reside in the province for which I am appointed during my term in office as
a Senator.
3)
I am not and have not been, to my knowledge, involved in any activity that would conflict, or give reasonable apprehension of any
conflict, with an appointment to the Senate.
4)
I have voluntarily disclosed any personal conduct in my past with respect to the principles and standards expected in public life, ethics and
integrity that would, if publicly disclosed, negatively impact the perception of my appointment to the Senate or the reputation of the
Senate. (attach separate sheet if applicable).
5)
I undertake to respect the confidentiality of the Senate appointment process, including the contents of my application, any communications
with the Advisory Board, the Privy Council Office, or any other federal government organization in relation to this appointment process.
6)
I acknowledge that it is my responsibility to ensure that my application is complete, and that it includes all mandatory information and
required supporting documentation, and that my failure to submit all required information in a single complete application will result in
my candidacy not being considered.
Signature
January 2016
Date
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PART II – DEMOGRAPHIC AND DIVERSITY INFORMATION (OPTIONAL)
Note: Fluency in both official languages will be considered an asset.
First official language
English
French
Proficiency in second official language
FRENCH
Unilingual
Limited
Functional
Fluently bilingual
ENGLISH
Unilingual
Limited
Functional
Fluently bilingual
Other
Note: In carrying out its work, the Advisory Board will seek to support the achievement of a gender balance and an adequate representation of
minority, linguistic, ethnic and Indigenous communities in the Senate. In order to assist the Advisory Board in assessing your application, you may
voluntarily self-identify with respect to any of the categories set out below.
Member of a visible minority
Specify:
Person with disability
Specify:
Indigenous person
First Nations, Status Indian, Non-status Indian
Inuit
Métis
Linguistic community member
Specify:
Ethnic community member
Specify:
PART III – CERTIFICATION (MANDATORY
I hereby certify that the information set out by me in this document is true and correct.
Signature
Date
Instructions: When complete, please submit a scanned version of your signed application together with all required
supporting documentation in PDF or TIF format to [email protected].
Only complete applications submitted with all required supporting information will be accepted. All
applications must also be supported by a nomination from an organization (submitted separately).
Complete application packages must be received no later than 12:00 p.m. Eastern Standard Time on
February 15, 2016. Late or incomplete application packages will not be considered.
Before submitting your application package, please check that you have provided all of the following
information:
Completed all information in this application
Copies of government-issued photo identification to prove citizenship, date of birth, residence
Institutional documentation (e.g., deed, lease agreement, bank statement) to prove the requirements
listed in section B for property, residence and net worth and net value of real property.
Resumé, curriculum vitae or biography (maximum 3 pages)
Personal statement outlining how you meet the criteria set out in section E (maximum 1 page)
References (3)
Completed and signed Background Check Consent Form
Signature on section I of Part I
Signature on Part III
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We thank you for your application. Only candidates selected for further consideration will be
contacted.
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January 2016
January 2016
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