New-Brunswick-Drop-off registration form

For association usage only

Invoice: ___________________________________

GL # ________________ Date: _______________

HST (15%) __________________

Sub-total: __________________
Total: ______________________

Prepared by ________________________________

Signature __________________________________

Company Name*

Company name

Contact Information*

First NameLast Name

Title*

Title

Email*

example@example.com

Phone Number*

Area CodePhone Number

Mailing/Admin Address*

Street Address

CityProvince

Postal Code

Collection Facility Address*

Street Address

CityProvince

Postal Code

**Please note that the Collection facility address is the one that will be listed on the Atlantic Used Oil Management Association's website.

HST #*

Indicate your HST number

Opening hours*

	Opening	Closing
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Collector's Name

Collector

*If you haven't found your Collector yet, choose one servicing your area using the collector finder tool on our website.

Where have you heard about Atlantic Used Oil Management Association?*

Visit from a representative, television, website, magazines, newsletters, etc.

This agreement authorizes the Atlantic Used Oil Management Association to register your company with the Atlantic Used Oil Management Association as a collection facility for used oil and antifreeze, used oil filters, used containers of oil and antifreeze (including used containers of 50 litres or less, break cleaner and lubricant aerosol containers) for the general public.

Your information will be posted on our website or given verbally to those who call in. You agree to function as a collection facility for a minimum of 1 year. As such, you agree to offer the drop-off service free of charge to the public. You are responsible for contacting the Atlantic Used Oil Management Association to report any changes that occur to the information posted on the website.

The Atlantic Used Oil Management Association will send you a one-time sign-up bonus of $ 100.00 plus taxes after 3 months of operation as a thank you for assisting the Atlantic Used Oil Management Association program. Your company will continue to be displayed on our website as an active collection facility until such time as you request to be removed.

I, {contactInformation}, {title}, declare to be duly authorized to act herein and certify that our company, association or municipality, {companyName}, acts in accordance with applicable laws and regulations.

Signature*

I confirm this signature.

Date*

DayMonthYear

Drop-off Registration Form