Village of Kelliher Application for Utility & Waste Collection Services
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Name(s): (First and Last) *
Mailing Address: *
Civic Address: *
Phone Number: *
Email: *
Connection Date:
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Are you the PROPERTY OWNER or RENTER? *
I/We hereby acknowledge that there is a non-refundable $50.00 connection fee. *
I/We hereby acknowledge that a refundable security deposit of $150.00 is required prior to service commencing at the above address and that the Village of Kelliher may apply that deposit to any balance if in the opinion of the Village of Kelliher it is acceptable. *
Accounts balance are ultimately the responsibility of the registered owner(s). In the case where the applicant is not the registered owner(s) of the civic address above, I/We acknowledge the Village of Kelliher provides copies of the utility notices to the registered owner(s) of the civic address above. *
*In accordance with Section 24 of The Local Authority Freedom of Information and Protection of Privacy Act, the personal information collected on this form will be used for administrative purposes related to the Village's activities*
Terms and Conditions:
By completing this form, you acknowledge that you are responsible for the completeness and accuracy of the information you provide. Any false or misleading statement with respect to this form may result in the denying of your application and refusal of service. All personal information provided on this form is collected by the Village of Kelliher for the purpose of determining entitlement of the applicant for the provision of services described herein. In the performance of those services, the personal information is collected, used, and disclosed under the Authority of Access to Information and Protection of Privacy Act and any other provincial laws, regulations, and policies applicable to the protection of personal information. By submitting this form the applicant consents to the collection, use, and disclosure of personal information by the Village of Kelliher for the provision of services. This acknowledgement shall be governed and constructed in accordance with the laws of Saskatchewan.   *
Date this form was filled out: *
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*Please note, after completion of this form you are still required to go to the Village office and pay the $150 refundable deposit*
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