Designated Smoking Area Request Form

Required fields are marked with an asterisk (*)

Contact information
Location information
In accordance with Section 485 of the Municipal Government Act (MGA), the personal information collected on this form will only be used by municipal staff and, if necessary, individuals under service contract with the Halifax Regional Municipality for purposes relating to the processing of your application for a Designated Smoking Area. If you have any questions about the collection and use of this personal information, please contact the Access and Privacy Office at 902-490-7460 or
Enter the characters shown in the image.