Medical Alert Pesticide Program Form

Citizens wishing to restrict application of pesticide on City property within 30 metres of their residence and/or receive pre-notification of pesticides applications within 100 metres of their residential property are asked to provide the following information:

Contact Information

Salutation:

Mr.Mrs.Ms

First name:

Last name:

Home phone:

Work phone:

Fax:

Email

Site Address:

Postal Code:

Mailing Address (if different than above):

Add another person

Type of Service Requested

Please choose one or both options:

Restrict Application of (choose one) within 30 metres of residential property. 

HerbicideInsecticideAll Pesticides

Pre-notification (choose one) - within 100 metres of residential property.

HerbicideInsecticideAll Pesticides

Reasons

Please state the reason(s) for the requested service:

Is medical verification included (All information is strictly confidential):

YesNo

Upload your document here

Confirmation

Date

By checking this box I confirm that all the information I have provided above is true and correct and that I am requesting the service(s) checked off in the “Type of Service” area of this form.

Captcha

Please enter the characters you see in this picture:

Characters

This helps prevent automated form submissions. If you are not sure what the characters are, make your best guess. You will have another try in the next screen.

FOIP Statement

This personal information is being collected under the authority of section 33(c) of the Freedom of Information and Protection of Privacy (FOIP) Act. The City of Edmonton will use this information for purposes necessary to and consistent with administering the exemption to discontinue the application of pesticide within 30 meters of your residential property and/or to receive pre-notification of pesticide applications within 100 meters of your residential property. The privacy provision of the FOIP Act protects all personal information collected by the City of Edmonton. If you have any questions regarding the collection or use of this information, please contact the program coordinator at 780-423-1465.

For More Information