NOTE: You must submit a form for each individual housing unit. Business/Farm Name: * Owner/Operator Name: * Phone Number: * Email Address: * Business/Farm Address: * City/Town: * Postal Code: * House Details House Name: House Address: * City/Town: * Postal Code: * Water Supply: * Municipal Well Cistern/Hauled Municipal Sewage System: * Municipal Septic System Proposed Occupancy: * - Select -1234567891011121314151617181920212223242526272829303132333435363738394041424344454647484950 Expected Date of Workers Arrival: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2023202420252026 Are workers fluent in English? * Yes No Please list any other languages spoken by workers: All IAW housing accommodations must comply with all local building, fire, zoning and any other relevant municipal requirements. I have consulted with my local Municipality, including Building and Fire departments, for the use of this premises: * Yes No The information on this form is collected under the authority of the Health Protection and Promotion Act in accordance with the Municipal Freedom of Information and Protection of Privacy Act and the Personal Health Information Protection Act. This information will be used for the delivery of public health programs and services; the administration of the agency; and the maintenance of healthcare databases, registries and related research, in compliance with legal and regulatory requirements. Any questions about the collection of this information should be addressed to the Chief Privacy Officer at 1-800-265-7293 ext 2975.
