Herbicide Exemption Request Form

Citizens wishing to restrict application of herbicides on City property within 5 metres of their residence are asked to provide the following information:

Contact Information

Salutation

MrMrsMs

First name:

Last name:

Home phone:

Work phone:

Fax:

Email:

Site Address:

Postal Code:

Mailing Address (if different than above):

Add another person

Type of Service Requested

Please choose one or both options:

Option 1 - Discontinue Chemical Trimming on City parkland along fence line(s) of above stated property.Option 2 - Discontinue broadleaf weed control on City parkland within 5 metres of above stated property.

Confirmation

Date

By checking this box I confirm that all the information I have provided above is true and correct and that I am requesting the service(s) checked off in the “Type of Service” area of this form.

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FOIP Statement

This personal information is being collected under the authority of section 33(c) of the Freedom of Information and Protection of Privacy (FOIP) Act. The City of Edmonton will use this information for purposes necessary to and consistent with administering the exemption to discontinue the application of herbicide along the fence line of your residential property and/or within 5 meters of your residential property. If you have any questions regarding the collection or use of this information, please contact the program coordinator (16th Floor, Edmonton Tower, 10111-104 Avenue NW, Edmonton AB, T5J OJ4, 780-423-1465).

Telephone	In Edmonton: 311 Outside Edmonton: 780-442-5311
TTY	780-944-5555
Email	311@edmonton.ca

Herbicide Exemption Request Form

FOIP Statement

For More Information

311 Contact Centre