NB-Collection facility registration form

For UOMA NB 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

Company Address *

Street Address

City	Province
Postal Code	Country

Collection Facility Address *

Street Address

City	Province
Postal Code	Country

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 in our collector's list serving your area.

Where have you heard about UOMA-NB? *

Television, website, magazines, newsletters, etc.

This agreement authorizes UOMA NB to register your company with UOMA NB 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 UOMA NB 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 NB to report any changes that occur to the information posted on the website.

UOMA NB 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 NB 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

Collection Facility Registration Form