Required fields are marked with asterisks (*)

Welcome

Please complete this application form and include the required income verification. If you prefer not to submit this form online you may fill it out, answering all the required questions and either mail it or drop it off to City of Elliot Lake, 45 Hillside Drive North, Elliot Lake, ON P5A 1X5. To the attention of: Access Pass

Type of Card

New Card

Renewal from Previous Year

Revision Required to Present Card

If approved would you like your affordable access card mailed to you?

Yes

First Name

Middle Name

Last Name

Street Address (PO Boxes will NOT be accepted)

City, Province

Postal Code

Daytime Telephone Number

E-Mail Address

Date of Birth

Gender

Male

Female

Other

Prefer Not to Answer

Do you have a Spouse or Partner or Dependents presently living with you?

Yes