Required fields are marked with an asterisk (*) To be completed by applicant Account number * Contact name * Company name Telephone * Alternate telephone Email Email Email * Confirm email * Service location Street number and unit number * Street Name and type * City / Community * Province * Postal code * Is the mailing address the same as service (civic) address? * Yes No Mailing address Street number and unit number Street name and type Province Postal code Nature of Business Information A customer may be eligible for a wastewater rebate if the customer uses more than 1,000 m3 of water in a one year period and they can demonstrate to the satisfaction of the Commission that the volume of Wastewater Discharged by the Customer into the Commission's Wastewater System is less than the volume of water used by the Customer. Please note, the rebate does not apply to the Wastewater Discharge Base Charge, nor to leakage or wastage from a metered water supply. Please provide a description of why the volume discharged to the wastewater system is less than the volume of water used by the property: Explanation * Other Questions or comments Access and Privacy In accordance with Section 485 of the Municipal Government Act (MGA), the personal information collected on this form will only be used by Halifax Water staff for purposes relating to the provision of water and/or wastewater/stormwater services. If you have any questions about the collection and use of this personal information, please contact Customer Service at (902) 490-4820 or CustomerService@halifaxwater.ca. What code is in the image? * Enter the characters shown in the image.