SPECIAL ACCOMMODATION RECYCLING COLLECTION SERVICE APPLICATION

SPECIAL ACCOMMODATION RECYCLING COLLECTION SERVICE APPLICATION
PLEASE READ CAREFULLY:

This form is intended for residents requesting accommodation related to assisted recycling collection services. It must be completed by the resident(s) residing at the address stated in this form. Please have your physician’s note ready prior to proceeding with the online application as you will be required to upload a copy in the form.

Purpose of Collecting Your Personal Information for the Application of Special Accommodation Recycling Service:

By providing your personal information to Circular Materials, you consent to the collection, use and disclosure of your information by Circular Materials for: (1) purposes of evaluating your request for accommodation and (2) permit Circular Materials to share only your municipal address, phone number and email address (and not any other personal information) to its recycling collection operator and/or contractor(s) for the purpose of facilitating the provision and accommodation of recycling receptacles under the provincial recycling collection program (Ontario’s Blue Box regulation). This may include the delivery and pick up of recycling carts, and any necessary accommodations.

Use and Disclosure of Personal Information:

You consent to the use of your personal information by Circular Materials for the purpose outlined above, and to the disclosure of your municipal address and phone number to the recycling collection contractor(s) engaged by Circular Materials for the purpose of contacting you directly to determine your specific accommodation requirements. This includes ensuring the effective collection of recycling receptacle(s).

Your personal information will be used only for the purposes described in this consent and will not be disclosed for any other purpose without your further consent, unless required or permitted by law.

Retention and Protection of Personal Information:

Your personal information will be retained only for as long as necessary to fulfill the purposes for which it was collected and to comply with applicable legal requirements. The parties above will take all reasonable precautions to protect your personal information from unauthorized access, disclosure, or misuse.

Your Rights Under PIPEDA:

Under the Personal Information Protection and Electronic Documents Act (PIPEDA), you have the right to:
- Access your personal information held by Circular Materials.
- Request corrections to your personal information if it is inaccurate.
- Withdraw your consent at any time, subject to legal or contractual restrictions. *Note: If you withdraw your consent, you will not be provided an accommodation.
- To exercise these rights or for more information about how your personal information is handled, please visit www.circularmaterials.ca.
Duration of Consent:

This consent remains in effect for as long as you require special accommodations for recycling collection services, or, until you withdraw your consent in writing. You may withdraw your consent at any time by contacting Circular Materials at: customerservice@circularmaterials.ca.

PLEASE READ BELOW:

By submitting this form, I acknowledge that I have read and understood the purpose of the collection, use, and disclosure of my personal information, and that I consent to the practices described above.
I Agree and Consent to the Above Disclosure*

RESIDENT INFORMATION
Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Address*
Nature of Disability*
Accommodation Requirement Dates*

Type of Collection Container Provided To Resident(s)
Please Select All That Apply*

Blue BoxMedium Cart (240 L)Large Cart (360 L)

I/we acknowledge and certify that:

(a) My/our temporary or permanent physical disability is such that I/we am/are unable to place our recycling container to the curb for collection.

(b) There are no other residents at the above address over the age of 12 who are capable of setting out the recycling container to the curb for collection on our behalf.

(c) There is no other person (a friend, a relative) available to set out our recycling container to the curb for collection on our behalf.

(d) I/we will notify Circular Materials, if any of the above conditions change within 14 days (2 weeks) of the change in circumstance (e.g., temporary physical disability has been resolved, move to a new address, or a change in occupancy such that the accommodation is no longer needed).

(e) I/we understand that the designated collection location on the property can only be approved by Circular Materials.

(f) I/we understand that the local contractor may be required to schedule a site visit at my residence to support my recycling accommodation needs.

PLEASE READ BELOW:

I/we understand that when collecting recyclable materials, the contractor cannot enter any dwellings on my property(garage etc.) or enter my property (back yard, alley etc.) beyond what is visible from the curb where my recycling is currently being collected.(Note, if this application is approved, it will be subject to an annual review and the service may be terminated if the above conditions no longer apply.)
I Acknowledge The Statements Above*
Signature(s) of Resident*

Clear

Physician Information

Please complete the information below and upload the supporting physician’s note. The physician’s note should confirm the resident’s temporary or permanent physical disability and need for assisted collection services.
Physician Name*

PrefixFirst NameLast Name
Physician Address*

Street Address

Unit Number (if applicable)

CityProvince

Postal Code
Physician Phone Number*
Physician Email*
example@example.com
CPSO Number*
Unique reference number for each physician
Please upload a confirmation note from your physician outlining the resident(s) need for assisted collection services.*

Cancelof
Should be Empty:

SPECIAL ACCOMMODATION RECYCLING COLLECTION SERVICE APPLICATION

RESIDENT INFORMATION

Type of Collection Container Provided To Resident(s)

Physician Information