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Form Lic/gam 5471 - List Of Elected Executive - Alberta Gaming And Liquor Commission Page 2

ECRETARY

REASURER

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Date of Birth:

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Postal Code

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AST

RESIDENT

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Date of Birth:

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Business Phone:

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Term Expiry:

OSITION

ELD

Print Full Name:

Date of Birth:

Mailing Address:

Postal Code

Residence Phone:

Business Phone:

Fax:

Email:

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Term Expiry:

OSITION

ELD

Print Full Name:

Date of Birth:

Mailing Address:

Postal Code

Residence Phone:

Business Phone:

Fax:

Email:

(

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)

Term Expiry:

OSITION

ELD

Print Full Name:

Date of Birth:

Mailing Address:

Postal Code

Residence Phone:

Business Phone:

Fax:

Email:

(

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(

)

(

)

Term Expiry:

OSITION

ELD

Print Full Name:

Date of Birth:

Mailing Address:

Postal Code

Residence Phone:

Business Phone:

Fax:

Email:

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The information you are providing on this application form is collected under the authority of the Gaming and Liquor Act, Gaming and Liquor Regulation,

and the Freedom of Information and Protection of Privacy (FOIP) Act, section 33(c). The information is strictly for the use of the Alberta Gaming and

Liquor Commission in assessing your eligibility. Your personal information is protected by Alberta’s FOIP Act and can be reviewed upon request. If you

have any questions about the collection or use of the information, please contact Alberta Gaming and Liquor Commission, 50 Corriveau Avenue, St.

Albert, Alberta T8N 3T5 Telephone: 780-447-8600, Toll-free: 1-800-272-8876.