Registration Form As a resident of the Maldon district, you are invited to join the Maldon District Citizens' Panel to have your say on current issues and Council services. The Citizens' Panel will meet a maximum of four times a year and residents who sign up to the Panel will be invited to attend a few of these meetings to discuss issues affecting the district. Meetings will be themed and up to 20 members will be selected to attend each meeting. As a result it is unlikely that you will be asked to attend all the meetings. If you want to join the Panel, please complete all the questions in the survey as clearly as possible. We need these details to make sure the Panel is made up from a wide range of residents with different backgrounds and to be able to contact you again. For further information please contact Jo Bellamy from Maldon District Council on 01621 876281 or e-mail jo.bellamy@maldon.gov.uk

Your Interests Q1 How interested are you in the following issues?   Very interested   Quite interested   Neither   Not interested   Not interested at all   Benefits and Revenues           Customer Service and Facilities           The Environment incl. waste and recycling           Leisure and Parks           Community issues incl. crime and disorder           Housing           Planning incl. economic development and tourism

Q2 How often do you use the following services in the district?   Within the last week   Within the last two weeks   Within the last month   Within the last 6 months   Within the last year   Never   Refuse collection             Recycling collection             Car parks             Leisure facilities             Parks and Open Spaces             Customer services i.e our Contact Centre by phone or Meet and Greet in person             Housing services             Planning services incl. economic development and tourism             Benefits service

Your details
Q3 Title (please select from the list)   --Click Here--MrMrsMissMsOther (please state below)   Other Q4 First name Q5 Surname		Q6 Address Q7 If you have an e-mail address, please write this in the box below.

About You
Q8 Are you?   --Click Here--MaleFemale In order to join the Panel, you need to be 18 or over. If you are under 18 and keen to have your voice heard, find out more about Maldon & District Youth Council by contacting Clare Lawrence on 01621 875821.		Q9 Please tell us your age:   --Click Here--18-2425-3435-4445-5455-6465-7475 years and over

Q10 Which of these groups do you consider you belong to? Tick one only.   --Click Here--White: BritishWhite: IrishWhite: Other WhiteMixed: White and Black CaribbeanMixed: White and Black AfricanMixed: White and AsianAsian or Asian British: IndianAsian or Asian British: PakistaniAsian or Asian British: BangladeshiAsian or Asian British: Other AsianBlack or Black British: CaribbeanBlack or Black British: AfricanBlack or Black British: Other BlackChineseOther (please state below)
Other ethnic group

Q11 Do you consider yourself to have a longstanding illness, disability or infirmity?   --Click Here--YesNo

Q12 If YES, does this illness or disability limit your activities in any way?   --Click Here--YesNo

Q13 In total how long have you been living in the Maldon District?   0-6 months 7-12 months 1-2 years 3-5 years 6-10 years 11-20 years More than 20 years

Thank you for completing this survey By completing and submitting this survey you are applying to become a member of the Maldon District Citizens' Panel. You can ask to be removed from our mailing list at any time. For more information please see the Frequently Asked Questions sheet on the Council's website (www.maldon.gov.uk)