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2. 
4. Date of Request*
   Date of Request
6. Account Number*
10. Names on Account
12. First Name*
13. Last Name*
15. First Name
16. Last Name
20. Service Address*
22. City*
23. Province*
24. Postal Code*
28. Phone Number*
29. Alternate Phone Number
31. Email Address
35. Date of Birth*
    Date of Birth
37. Verification *

    1. Birth Certificate
    2. Drivers Licence
    3. Passport

    1. Senior Card
    2. Other
39. Please Upload Verification Document*
41. Applicant Resides At This Property*

    Please note that to receive the discount, the senior must occupy the property.

    1. Yes
45. I, the applicant, certify the above information is correct*

    1. Yes
47. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
49. Electronic Signature*
51. Note:

    This information is being collected for the purpose of providing a senior garbage discount on utility services pursuant to the provisions of the Municipal Government Act and its regulations, and pursuant to Section 32C of the Freedom of Information and Protection of Privacy Act. If you have any question about the collection and distribution of this information, you may contact the City of Brooks FOIP Coordinator at (403) 362-3333.

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53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit

* indicates a required field