Clerks Department
55 Zina Street, 2nd Floor
Orangeville, ON L9W 1E5
519.941.2816
info@dufferincounty.ca
Special Occasion Certificate Request
Name of recipient (s):
Name(s) will appear exactly as specified above
Type of Event:
Wedding Anniversary Birthday Other - Please specify below
Years/Age:
Date of event:
Contact information:
Name:
Address:
City: Prov: Postal Code:
Phone #:
Email:
Would you like:
to be notified when the Certificate is available for pick up
the certificate to be sent in regular mail to the address provided above
Please allow 10 business day to process.
Personal information on this form will be used for the purposes of creating a special certificate,
pursuant to Section 27 of the Municipal Freedom of Information and Protection of Privacy Act, R.S.O.
1990, c.M.56, as amended.
Questions about this collection should be directed to the Clerk (519) 941-2816 Ext. 2503.
