Assisted Waste Collection Application Form

Agreement

By filling in and submitting this form, you agree that the following statements are true:

I have a mobility-related disability which prevents me from getting my recycling or garbage to the curb/lane for regular pickup.
There is no one living at the same address who can take my recycling or garbage to the curb/lane for me.
I have reviewed and agree to comply with the Guidelines and Regulations for the Assisted Waste Collection Service.
I understand that I may be required to provide supporting documentation from a health care provider substantiating information regarding my disability before final approval is provided.

Eligibility, duration of service, and other information can be found on the Assisted Waste Collection page. It is recommended that you read all the information on that page before applying.

Applicant Information

First Name: * Enter your first name.

Last Name: * Enter your last name.

Telephone Number: * Enter your telephone number in 555-555-5555 format.

Most convenient time of the day to phone you: Enter the time of day (hh:mm am/pm) when you would like us to contact you.

Address: * Enter your address.

Postal Code: * Enter your postal code.

The condition that prevents me from taking my waste to the curb/lane is: Long Term / PermanentTemporary

Please state the estimated duration of your condition (min. 3 months):

Your email address: Enter your email address so we can contact you about this application if necessary.

Additional comments: Enter any additional information

This information is being collected under the Authority of Section 33 (c) of the Freedom of Information and Protection of Privacy (FOIP) Act and will be used to contact you regarding your application for assisted waste collection. Your personal information is protected by the privacy provisions of FOIP. If you have any questions about the collection, use and disclosure of your personal information, contact the City of Edmonton at 311.

Before clicking "Submit", please ensure that you have read the agreement at the top.