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2. Last Name:*
3. First Name:*
5. Mailing Address: *
7. City: *
8. Province:*
9. Postal Code: *
11. Phone Number:*
12. Email:*
14. PIN NUMBER (4 digits)*

    Please pick a 4 digit numerical pin number (between 1000-9999) that you will use to access the site. The County will be assigning you a access number as well to use with the pin number.

16. 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, and 2) by signing in this alternate manner, your electronic signature is valid and binding upon you to the same force and effect as a handwritten signature.

    1. I agree.
18. Electronic Signature
20. Payments

    Payments can be made in person at the Administration office (cash, cheque or debit), online or telebanking. Please set up a new payee and select "Utility" option &  account number "999931" when making your payment online & telebanking.

    Please allow 1-2 business days for payments made at the County office and 3-4 business days for online, telebanking or Option Pay to apply funds to your account. 

22. Waiver

    We will use all reasonable means to protect the confidentiality of your personal data (Access and PIN codes) while in our possession or control. While we’re committed to keeping your personal data secure, it’s also important for you to do your part to help minimize the risk of fraud and unauthorized transactions on your account. The County will not be liable for any financial losses due to fraud, theft or unauthorized use of personal data.

24. Protection of Privacy Act

    The personal information collected through this Application for Bulk Water in Gwynne form is for the purpose of managing Bulk Water applications. This collection is authorized by Section 4(c) of the Protection of Privacy Act. For questions about the collection of personal information, please contact the County of Wetaskiwin Privacy Officer: email legislativeservices@county10.ca; telephone 780.352.3321.

    
    

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

    This field is not part of the form submission.

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