Heritage Archive and Interactive Heritage Register Map Consent Form

Registered owners with properties included on the Township’s Heritage Register are invited to include their properties on the Township’s Digital Archive and Interactive Heritage Register Map. By completing the form below registered owners are opting into their properties inclusion on the Township’s Digital Archive and Interactive Heritage Register Map.

Note: This consent form can only be completed by the registered property owner.

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 Interactive Heritage Register Map; and/or,
Take exterior images of the buildings with heritage features on my property.

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

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 Interactive Heritage Register Map that only the historical information about my property will be included. No information related to property ownership will be included on either the Digital Archive or Online Heritage Tour.

I understand that if I grant permission to the Township to take exterior photos of buildings on my property with heritage features that the Township may use these photos as part of the Township’s Digital Archive and/or Interactive Heritage Register Map.

I understand that if I submit any images of my property they may be used for the Township’s Digital Archive and/or Interactive Heritage Register Map.

Consent Confirmation *

I have read, understood and agree to the consent confirmation.

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 photos collected for future Township publications.

Confirmation of Photo Consent

Yes, I consent to the Township using the photos collected for future Township publications.

Signature

Personal information on this form is collected under the authority of the Municipal Act and will be used to confirm participation on the Township’s Digital Archive and Online Heritage Tour and is maintained in accordance with the Municipal Freedom of Information and Protection of Privacy Act. Questions regarding the collection of this information may be directed to the Township Clerk’s office.