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2. First Name*
3. Last Name*
5. Company (if applicable)
7. Phone*
8. Email*
10. Property Address*
12. City*
13. Province*
14. Postal Code*
16. Coquitlam Water Utility Account Number*

    Found on the top-right corner of your utility bill.

18. If you are not the property owner, please provide the owner’s name and contact information
20. Owner(s) Name
22. Owner(s) Phone
23. Owner(s) Email
25. Are you applying for one or two toilet rebates?*

    max. 2 per dwelling

    1. One toilet rebate

    1. Two toilet rebate
27. Old Toilet(s) Flow Rating*
29. New Toilet(s) Manufacturer/Brand*
30. Model Name*
32. Flow Rating

    max. 4.8L or 1.28 gallons for single; 4.1/6L or 1.1/1.6 gallons for dual

33. Canadian Certification Type

    Found on the inside or outside of the water tank.

    1. CSA
    2. Warnock Hersey
    3. CUPC
35. Supporting Documents
37. Upload photo of your receipt showing purchase of new toilet(s) *

    (within 90 days of your application)

39. Upload photo of old 13L toilet(s) still installed*
41. Upload photo of old 13L toilet(s) removed with tank(s) cracked/broken*
43. Upload photo of new toilet(s) installed*
45. Did this rebate program encourage you to replace your toilet?*

    1. Yes
    2. No
47. Freedom of Information and Protection of Privacy*

     By submitting this form, you are consenting to the collection, storage, use and disclosure of your personal information. The City has authority to collect, use and disclose your information for the purposes of the City’s Toilet Rebate Program in accordance with Section 26(d) of the Freedom of Information and Protection of Privacy Act. Your personal information will be disclosed to a third-party service provider (i.e. website host Civic Plus) located in Canada for the purpose of processing your request.  Should you have any questions or concerns about the collection of your personal information please contact Julie Kanya, Manager Environmental Education and Enforcement, by email or call 604-927-3503.

    1. I agree
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49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field