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Consent to Disclose Business Information for Advertisement Purpose

2. Date:
4. Licence Type:
6. Business Name
7. Contact Person
9. Address
11. City
12. Province
13. Postal Code
15. Phone Number
16. Cell/Alternative Number
18. Business Description:
20. CONSENT TO DISCLOSE BUSINESS INFORMATION:
    I give the Town of Slave lake permission to release any of the above information in response to general public inquiry for specific services.
22. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
24. Electronic Signature
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field