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APPLICATION FOR CLEAR BAG EXEMPTION FOR MEDICAL WASTE

This application is for residents of the Township of Havelock-Belmont-Methuen with a medical condition to apply for an exemption from the clear bag curbside collection and Transfer Station waste disposal. To be eligible, applicants must provide proof of medical condition that is verified by a medical professional.

First Name:

Last Name:

Phone Number:

E-mail Address

Property Address:

Mailing Address:

Important Information

Please attach a note signed and dated by your medical professional which includes your medical professional's name, address, phone number, and acknowledges and certifies that you generate garbage due to a medical condition. It is not necessary for the medical practitioner to state the reason for your exemption.

Please attach a note that has been signed and dated by your medical professional

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Agreement - Terms and Conditions

I acknowledge that:

If the exemption is not longer required, I will notify the Township of Havelock-Belmont-Methuen.
I will notify the Township of Havelock-Belmont-Methuen if I move.
I understand that the Township of Havelock-Belmont-Methuen may change the clear bag collection requirements.
I will not set out hazardous-medical waste incuding syringes, and unused medication for curbside collection. Instead, I will properly dispose of the waste.
By completing this application, I certify that the information provided is true and accurate.
For residents receiving curbside garbage collection, please be advised that your address will be provided to the curbside garbage collection company to notify them that your address is "clear bag exempt"

Date:

Signature:

Clear

Notice with respect to the collection of personal information. Personal information provided on this form is collected under the authority of the Municipal Act and in accordance with the Municipal Freedom of Information and Protection of Privacy Act. Your personal information will be used by staff of the Township of Havelock-Belmont-Methuen in the administration of the clear bag exemption for medical waste. Questions regarding the collection use, and disclosure of your personal information can be directed to the Township Clerk at 1 Ottawa St E, Po Box 10, Havelock ON, K0L 1Z0 or 705-778-2308 or email havbelmet@hbmtwp.ca

OFFICE USE ONLY

Manager of Public Works Approval:

Date

Ο Verification of Ownership _____________

Comments: