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Application for medical exemption

Applicant information

Name

Phone number

Address If you live in a suite, use a comma (eg. 2204, 500 KINGSLAND RD SE)

Terms and conditions

I am applying for this medical exemption due to a medical or health-related situation only
I acknowledge that this exemption application is for residential use only and is not meant to be used for excess waste generated by a home-based business (i.e. day homes etc.) and any information that is falsely supplied will be deemed fraudulent and will result in a fine pursuant to the Waste Management Bylaw No. B-07/2017
The excess bag tags will be used by the above-noted residence only, and will not be transferred or re-sold. I acknowledge that the bag tags hold no cash value
I acknowledge that the City does not accept hazardous bio-medical waste, including but not limited to, syringes, hypodermic needles, and sharps and agree that hazardous waste products will be disposed of properly through syringe/needle return programs at participating pharmacies
I will notify the City and return any remaining bag tags if the exemption is no longer required
I will notify the City if I move, and provide the City with my change of address within ten (10) business days
Neither I nor another member of my household has already made an application for a medical exemption for the six (6) month exemption period currently being applied for

I agree to the terms and conditions

Yes

Verification

Name

Date

Signature I CERTIFY that [by displaying/typing my name above] the information contained in this application is true, and to the best of my knowledge is correct and complete. I understand that providing false information on this application is fraudulent and will result in a fine pursuant to the Waste Management Bylaw No. B-07/2017.

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FOIP (privacy statement)

The information on this form is collected under the authority of Section 33(c) of the Freedom of Information and Protection of Privacy Act ("the Act") and will be used solely for the purposes of administering the application process to receive excess waste tags pursuant to a medical exemption under the City of Airdrie's Waste Management Bylaw No. B-07/2017.

It will be treated in accordance with the privacy protection provisions of Part 2 of the Act. Questions concerning collection of this information can be directed to the Waste & Recycling Services at 21 East Lake Hill NE, Airdrie, Alberta T4A 2K3 or at 403.948.0246.