2. City of Beaumont Water Sampling Form
4. Full Address*
6. Postal Code:*
8. Unique Registration Code*
   Your unique code can be found on the direct mailer that you received.
10. Does your household water system currently have a reverse osmosis system or water softener connected?*

    1. Yes
    2. No
12. Contact Name:*
13. Contact Email:*
14. Contact Phone Number:*
16. Alternate Contact:
17. Alternate Phone Number:
21. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that:
    1) your registration 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.
22. Electronic Signature*
24. If you have questions contact:
    City of Beaumont
    Public Works
    Phone: 780-929-4300
    
25. The personal information requested on this form is being collected under the authority of the City of Beaumont Bylaw 382 and Section 33(c) of the Freedom of Information and Protection of Privacy (FOIP) Act. The information collected will be used for the purpose of registering your home for the Water Quality Sampling Program .
    
    If you have any questions about the collection or use of your personal information, contact the City of Beaumont’s FOIP Coordinator at:
    City of Beaumont's FOIP Coordinator
    5600-49th Street
    Beaumont, AB T4X 1A1
    Phone: 780-929-8782
Leave This Blank:


29. Submit

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