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2. I, the undersigned, hereby apply to the County of Wetaskiwin No. 10 for one application of Dust Control for the purposes of controlling dust along a local road adjacent to the land described below and I hereby acknowledge that I have been advised of and agree with the following conditions outlined in the Dust Control Policy.
4. Last Name (Please Print)*
5. First Name (Please Print)*
6. Date*
   Date
8. Mailing Address*
10. City*
11. Province*
12. Postal Code*
14. Subdivision Name
15. Subdivision Lot & Block Number
16. Phone Number*
18. Legal Land Description (Ex: NE 24-45-23-W4M)*
    Quadrant / Section / Township / Range / W 4 or 5 M
19. Rural Address
    Blue Sign
21. Required Distance*
    Metres
22. Amount Paid (Prior June 1)
    $6.50/metre x 5% GST = amount to be paid
23. Amount Paid (After June 1)
    $6.50/metre x 5% GST = amount to be paid
25. On-line Banking or Option Pay
    Confirmation Number or Transaction ID Number
26. Payment Method*
    -- Select One --On-Line Banking/Option Pay

    Must be paid in advance on-line.
28. Sample Map
    Click here for sample map
29. Upload Map *
31. Waiver
    I hereby remise, release and forever discharge the County, its officers, contractors, agents, servants, successors and assigns of and from all manner of actions, causes of actions, suits, debts, dues, accounts, covenants, contracts, claims and demands whatsoever which I shall or may have by reason of any cause, matter or thing, whatsoever, and without limiting the generality of the foregoing, from all claims for damages arising in any way whatsoever from the application of dust control material as described herein.
33. Collection of Personal Information
    The personal information on this form is collected under the authority of Section 33 (c) of the Alberta Freedom of Information and Protection of Privacy Act. The information will be used to process your application(s) and your name and address may be included on reports that are available to the public. If you have any questions on the collection and use of this information, please contact the FOIP Coordinator at (780) 352-3321.
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36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit Submit and Print

* indicates a required field