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.
Clerks Department
55 Zina Street, 2nd Floor
Orangeville, ON L9W 1E5
519-941-2816 x2500
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):
Years/Age: Date of event:
Contact Information:
Name:
Address:
City: Prov: Postal Code:
Phone #:
Email:
I would like:
to be notified when the Certificate is available for pick up.
the certificate to be sent via regular mail to the address provided above.
Please allow 10 business days for processing.
