City of Regina | Water Filter Request Application Form

First Name*

Last Name*

Middle Initial

Phone*

Email*

Utility Account Number*

Address*

Unit/Apartment

City*

Province*

Postal Code*

Address (if different from above)

City

Province

Postal Code

Delivery instructions (if any)

Confirmation of lead service connection*

City-side lead connection
Private-side lead connection
Water test showing high lead concentration

Which filter would you like to request?*

I am the registered owner of the property at the address indicated in Part B.*

Yes
No

I shall ensure that the filter and/or cartridges shall be used in accordance with the manufacturers’ recommendations at the property indicated in Part B.*

Yes
No

I acknowledge and agree that the City of Regina shall incur no liability arising from any use or installation of the filter and/or cartridges at the property indicated in Part B.*

Yes
No

By submitting this request application, I hereby acknowledge that I have read the application and that the information contained herein is true and accurate. I also hereby agree to complete all feedback and inspection requirements as outlined within the City of Regina Municipal Testing Program.*

Yes

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Part A: Applicant Information

Part B: Water Filter Installation Address

Part C: Water Filter Options

Part D: Declaration

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