Digital Archive and Heritage Mapping Consent Form

Name of Registered Property Owner *

First

Last

Email *

Phone

Address of Heritage Property *

Address Line 1

City

Province

Postal Code

I grant the Township of Puslinch permission to (Check all that apply) *

Include my property on the Township’s public Digital Archive; and/or,
Include my property on the Township’s Heritage Mapping; and/or,
Take exterior photographs of the buildings with heritage features on my property.

I allow Township staff to conduct a site visit and take exterior photographs of my property. *

Yes
No

I would like to be present during the site visit. *

Yes, I would like staff to email the approximate time they will attend my property.
No.

What time would you like the site visit to happen? Check all that apply: *

Consent Confirmation

I understand that by granting permission to the Township of Puslinch to include my property on the Township’s Digital Archive and/or Heritage Mapping that only the historical information about my property will be included. No information related to property ownership will be included.

I understand that I grant the Township permission to take exterior photos of buildings on my property with heritage features.

Consent Confirmation *

I have read, understood, and agree to the consent confirmation.
I do not consent.

Signature *

Clear Signature

Consent to Future Photo Use

The Township often uses photos in it’s advertising and promotion of Township services and programs. Please indicate below if you consent to the Township using the exterior photographs collected for future Township publications.

Confirmation of Photo Consent *

Yes, I consent to the Township using the photographs collected for future Township publications.
I do not consent.

Signature *

Clear Signature

Would you like to provide your own pictures of your heritage property?

Yes
No

Upload images of Heritage Property

Click or drag files to this area to upload. You can upload up to 10 files.