Nova Scotia - Collection facility registration form no Collector listing

For UOMA NS usage only

Invoice: ___________________________________

GL # ________________ Date: _______________

HST (15%) _________________

Sub-total: __________________
Total: ______________________

Prepared by ________________________________

Signature __________________________________

Company Name *

Company name

Contact Information *

First Name Last Name

Title *

Title

Email *

example@example.com

Phone Number *

Area Code Phone Number

Mailing Address *

Street Address

City Province

Postal Code

Collection Facility Address *

Street Address

City Province

Postal Code

HST # *

Indicate your HST number

Opening hours *

Opening

Closing

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Registered collector's Name

The collector is the company that will pick up the used products

Are you registering following a visit from one of our representative? *

Yes No

Which of our representative met with you? *

Where have you heard about the UOMA NS ? *

Television, website, magazines, newsletters, etc.

This agreement authorizes UOMA NS to register your company with UOMA NS as a collection facility for used oils and glycols (antifreezes), used oil filters, used oil, glycol (antifreeze) and diesel exhaust fluid containers of 50 litres or less (including cleaners for automotive parts 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 and offer the drop-off service free of charge to the public.

You are responsible for contacting UOMA NS to report any changes that occur to the information posted on the website. UOMA NS will forward you a one-time bonus of $ 100.00 plus taxes after 3 months of operation as a thank you for assisting the UOMA NS 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 *

Day Month Year

UOMA Nova Scotia - Collection Facility Registration Form