Recovery Assistance Request - Spring 2020 - Ottawa River Flooding 2019

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This form is to gather information that will aid in identifying households that still require assistance in recovering from the Spring Floods 2019. Submission of information is not a guarantee that work will be done on your property. A representative will be in touch with you as soon as possible to discuss your ongoing needs.

Name *

Street Number *

Street *

Municipality *

City of Pembroke

Town of Petawawa

Township of Laurentian Valley

Township of Horton

Township of McNab/ Braeside

Township of Whitewater Region

Other:

Province *

Ontario

Quebec

Postal Code *

Phone Number *

E-mail

Structure Type

Residential

Multi-Residential

Clear selection

Primary residence?

Yes

Clear selection

Damage Description & Work Required

Disclaimer

Team Rubicon Canada strives to identify the reason for data collection, and
achieve the highest standard to data protection. In submission of this request, the
homeowner acknowledges that information and data disclosed in this form may be
shared with local governments, and other NGOs within the scope of the disaster
response. Homeowner information and data is required strictly for operational purposes
(for example, making contact with homeowners after the reception of an electronic
form). All information and data submitted via this electronic form will be destroyed at the
end of the disaster response.

Any questions about TRC's privacy policy can be sent to privacy@teamrubicon.ca .

I understand and consent to the conditions outlined above.

Submit

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