Form Builder

Required fields are marked with asterisks (*)

Release of Information

Tenant Information

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

Identification (Select ONE of the following):
 
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Owner/Landlord Information

Preferred method of contact:
 

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.

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