Name (please print):

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Telephone Number:

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Street Address:

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Municipality:

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Postal Code:

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I hereby authorize the Government of Canada, the Province of Nova Scotia, the Provincial Department of Public Works, and/or the Federal Ministry of Health, to release to the Sierra Club of Canada, and all soil quality data and/or pollution information relating to my property near Muggah Creek. Additionally, I specifically authorize and direct the Federal Ministry of Health to release the soil sampling longitudinal and latitudinal data relating to my property to the Sierra Club of Canada.

I provide this authorization so the Sierra Club of Canada can continue with its independent evaluation and analysis of pollutants affecting the ecology of the Muggah Creek Watershed and affecting the residents living near the Muggah Creek. I understand that without further authorization from myself, that the Sierra Club of Canada or its agents will not use or release my name or my civic address for any public purpose or other purpose. However, that the data relating to my property may be so used, by itself or in conjunction with other data, or as data identified by street name.

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Signature

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Date

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Witness

Mail or deliver original, signed copy to:

Sierra Club of Canada National Office
Attention: Daniel Green
412-1 Nicholas Street
Ottawa, Ontario
K1N 7B7


For further information: 1-888-810-4204