Page Content Please note: The fields marked * are mandatory.First name*Please enter the required information.Last name*Please enter the required information.Mailing Address*Enter full mailing address including postal code Please enter the required information.City*Please enter the required information.Postal Code*Please enter a valid postal codeHome Phone*Please enter a valid phone numberCell PhonePlease enter a valid phone numberSocial AccountsFacebookPlease enter the required information.InstagramPlease enter the required information.LinkedInPlease enter the required information.XPlease enter the required information.WebpageWhere applicable, the City of Brampton may tag your professional or affiliated social accounts. Please provide the handles for your professional or organizational accounts.Please enter the required information.Media Release ConsentCheck to agree to privacy conditions*The personal information on this form is collected under authority of the Municipal Act, SO 2001, c. 25. The information will be used to process the Accessibility Award Nominations. Questions about the collection of personal information should be directed to City Clerk's Office, 2 Wellington Street West, Brampton, Ontario L6Y 4R2 905.874.2100 or accessibility@brampton.ca. Please review the City’s Privacy Statement for more information.YesNoPlease enter the required information.Check to agree to the use of images*I hearby grant and release to the City of Brampton the right to use photographs, audio tapes, and/ or videotapes in which I and/or my children appear in any materials such as videos, films, recordings, photographs or articles relating to the City of Brampton, its programs and services including, but not limited to, brochures, newsletters, annual reports or our Web site, whether broadcast on television, radio or any other medium. The personal information on this form, including images and recordings, is collected under authority of the Municipal Act, SO 2001, c. 25. The information will be used for promoting and/or publicizing the City of Brampton. Personal information may be disclosed to outside service providers for processing and production. Questions about the collection of personal information should be directed to Production Coordinator, 905.874.3603YesNoPlease enter the required information.Attachment 1*Attachment 2*Attachment 3* *Please type the letters appearing in the image above. Why do I need to do this?Please type the letters appearing in the image above. Submit Reset Cancel PrintPrivacy StatementPersonal information is being collected under the authority of the Municipal Act. The information will only be used to communicate with you regarding your inquiry. Questions about this collection may be directed to Service Brampton by calling 311 (within Brampton city limits) or 905.874.2000 (outside city limits). Please review the City’s Privacy statement for more information.
