Required fields are marked with asterisks (*)

Release of Information

Tenant Information

Property address:

Provide the name and identification of all the Tenants occupying the property. Please click on Add button to enter more tenants.

Tenant name:

Date of birth:

Identification (Select ONE of the following):

Driver's License

Social Insurance

Passport

Phone number:

Email address:

Add Remove

Owner/Landlord Information

Owner name:

Phone number:

Email address:

Preferred method of contact:

Phone

Upon submitting this application, I authorize the City of Medicine Hat to provide information regarding my utility account to my landlord as indicated above. This information includes requests for a final read on my utility account, and/or information regarding disconnection of utility services.

This agreement remains in effect until the tenant moves from the address.

By submitting this application/form you acknowledge and agree that any electronic signature provided by you herein is the same as a handwritten signature for the purposes of legality, validity, enforceability, and admissibility.

Please sign here:

Clear

Date signed:

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