Required fields are marked with asterisks (*)

Toilet Replacement Program Application

You will need to include a scanned receipt of your toilet purchase in this application.

The Toilet Replacement Program brochure provides more information on this rebate from the Town of Olds. If you cannot scan your receipt, this brochure includes a printable form.

I am a (choose one)

Homeowner

Property Manager

Full Name - as it appears on Utility Bill

Utility Account Number

Mailing Address (including Postal Code)

Primary Phone Number

Secondary Phone Number

NEW TOILET INSTALLATION INFORMATION

Installation Address (including postal code)

Year Built

Installed by:

Self

Plumber

Other

Make, Model & Name of Toilet

Store purchased from

Purchase Date

Number of toilets at this address

Please attach a copy of receipt

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Declaration

I declare that I have removed a 13L or 20L existing toilet and have installed an eligible 6L, 4.5L or 3L/6L dual flush toilet. I have read and understand the parameters of the program and understand that the Town of Olds is not responsible for the installation or functioning of the toilets.

I agree to the above Declaration

Agree

Privacy Statement

The personal information on this form is collected under the the Protection of Privacy Act and the Access to Information Act and will be used in order to process this form. See the Town of Olds Privacy Policy for more information.

Forms

Toilet Replacement Program Application

NEW TOILET INSTALLATION INFORMATION